Customer Service Medical
Resume:
KENYA L. DIXON
Torrance, Ca 90503
***************@*****.***
Cell # 310-***-****
CAREER OBJECTIVE
My objective is to secure a position within a highly organize Organization with a
Multi-disciplinary team that will utilize my skills, and allow growth and development.
EXPERIENCE:
Molina Healthcare 12/2013 - Present
Inquiry D/A Resolution Coordinator
oPoint of contact for submission/resolution of Provider Disputes
oAssesses and completes appropriate documentation for tracking/trending data
oConducts research in order to evaluate, respond and close incoming Provider Disputes
oReview Provider Disputes timely in accordance with all established regulatory guidelines
oResearch claims, and prior claim payment history.
oCoordinates workflow between departments and interface with internal and external resources
oInterfaces with internal departments and external resources and organizations.
oPoint of contact for submission/resolution of Provider Disputes
oAssesses and completes appropriate documentation for tracking/trending data
oConducts research in order to evaluate, respond and close incoming Provider Disputes
oReview Medicaid based case for accurately processed payment at Medicare rates.
oReview for correctly applied secondary payments/Medicare-Medicaid duals
Kelly Services (Noridian Medicare Healthcare Solutions) 07/2013 – 12/2013
Customer Services Representative
o Advise Providers on how the claim was processed and paid
o Review appeal for correct processing of claims
o Assist providers with Claim status, & Appeal status
oChecking member Medicare eligibility
oReview denied claims for non payment
oReview member Medicare Part B Benefits
oReview for Medicare secondary Payor (MSP) information,
oReview for Medicare Advantage plans, and HMO insurance
oAssist provider with system passwords, and set up
oEducate providers on the Interactive Voice Response system (IVR)
oAssist providers with paid claims that have been recouped
Aerotek (AppleCare Interim) 11/2012 – 02/2013
Claims Auditor
oReview of auditing claims, review of accuracy of billing submissions and pending records
oResearch dispute resolution, special projects, contract interpretation and review correspondence
oMaintain reports, analyze and review of questionable claims and resolution of auditing inquiries
oEnsure claims are adjudicated to be compliant with AB1455, State/Federal and DMHC laws
oRespond to the correspondence received in a timely manner and adhere to compliance guideline
All’s Well (HealthCare Partners Interim) 03/2012 – 10/2012
Claims Examiner
oProcessed over 750 claims on a weekly basis and 20% of which were manually adjudicated
oDetermined and verified patient eligibility, benefits, patient and insurance liability of payment
oPaid claims within a timely manner and pay claims based on Medicare RBRVS, Stop Loss
oReviewed fee schedules, provider payments and COB information between Medicare and HMO
oAssisted with clerical duties to complete the claims examining process and customer service
oExamined claims for adjudication, medical necessity and ensure proper coding was established
oResearched claims for improper coding, errors, issues, trends of compliance and Contract issues
oAudited claims for diagnosis in matching with correspondence of appeals and reprocessing
CareMore HealthPlan (Interim) 03/2011 – 01/2012
Claims Auditing/Contracts
oReview of auditing claims, review of accuracy of billing submissions and pending records
oResearch dispute resolution, special projects, contract interpretation and review correspondence
oMaintain reports, analyze and review of questionable claims and resolution of auditing inquiries
oEnsure claims are adjudicated to be compliant with AB1455, State/Federal and DMHC laws
oRespond to the correspondence received in a timely manner and adhere to compliance guideline
Prospect Medical Group 10/2006 – 03/2011
Provider Disputes/Resolution Appeals Analyst
oPerform Provider Disputes resolution and special projects for other departments
oMaintain reports, analyze and review DOFR requests, maintaining capitation reports
oEnsure claims are adjudicated to be compliant with AB1455, State/Federal and DMHC laws
oRespond and reply to Member and customer service calls regarding the adjudication of claims
oAssist members and Providers with denied claims, and advise what’s needed to correct denial
oReview EOB’s for correct billing and payment of claims
oResearch processing issues and/or problems and recommend solution for contract issues
oExperienced with IPA’s, MSO’s, HMO’s, PCP, PPO, Commercial and Managed Care contracts
oInterpret contracts and terms for researching of responsibility of Full and Shared risk contracts
oGather claims and reporting information for upper management review and resolution of disputes
oMaintain Managed Care compliance contracts, dispute resolution and grievance compliance
oImplement processes to identify under-allowed, incorrectly processed and denied claims
oComplete knowledge of ICD-9, CPT diagnostic and procedure codes
Pacificare Health Systems / United Healthcare 03/2001 – 10/2006
Contract Analyst II/COB Coordinator/Claims Examiner II
oAudited hospital and PMG entries and make recommendations to Network Management for rate and language changes in the contracts, terms and agreements
oReviewed DOFRs (Division of Financial Responsibility) for Full/Shared Risk contracts
oCommunicated closely with Network Management for coding and language in contracts
oReviewed the terms and contracts for all lines of business; Commercial and Managed Care
oHandled HMO, PPO HNS disputes, contract clarifications and grievances in contract issues
oExperienced and working knowledge of ICD-9, CPT, diagnostic and procedure codes
oMaintained the HNS dispute database and participant of the HNS interpretation team
oPerformed direct contact communication with Network Management and auditors
oProvided detailed analysis for problematic contractual terms setup at HNS
oReviewed, researched and audited HMO/PPO claims processing experience
oAssisted with customer services, claims processing, High Dollar, High Priority claims
oDetermined patient eligibility, verification of benefits and payment determination
oResearched claims, adjustments, write offs, member updates and history research
oCoordinated benefits for Primary and Secondary responsibility and customer service
oPaid claims in a timely manner to meet compliance, State, Federal and DMHC guidelines
oCompleted clerical general support duties performed to complete the claims examination
Pacificare Health Systems (Interim Position) 07/2000 – 03/2001
Contract Analyst II/COB Coordinator/Claims Examiner II
oProcessed over 350 High Dollar Priority claims, 95% of which were manually adjudicated
oPaid claims within a timely manner to meet compliance, State/Federal and DMHC protocols
oReviewed accounts for credit balances, overpayments, recoups and balances due
oContacted providers for claims status, collections of claims and patients for balances due
oAssisted with clerical duties performed to complete each project as requested per management
oFollowed up on Accounts Receivables/Account Payable and customer service
oCoordinated COB Primary and Secondary benefits and eligibility for billing purposes
oVerified eligibility, benefits, patient and insurance information for accuracy of billing
oAnalyzed contracts, disputes, grievances, Full/Shared Risk DOFRs an Capitated contracts
Healthcare Partners Inc. 08/1999 – 08/2000
Medical Claims Examiner
oProcessed over 600 claims on a weekly basis and 80% of which were manually adjudicated
oDetermined and verified patient eligibility, benefits, patient and insurance liability of payment
oPaid claims within a timely manner and pay claims based on Medicare RBRVS, Stop Loss
oReviewed fee schedules, provider payments and COB information between Medicare and HMO
oAssisted with clerical duties to complete the claims examining process and customer service
oExamined claims for adjudication, medical necessity and ensure proper coding was established
oResearched claims for improper coding, errors, issues, trends of compliance and Contract issues
oAudited claims for diagnosis in matching with correspondence of appeals and reprocessing
oAssist customer services with member denials
oEOB review for correct codes billed and payment of claim
Medaphis Physician Services 07/1997 – 08/1999
Account Auditor
oAudited accounts for payment allocation posting, account adjustments and write offs
oReviewed and researched medical billing, data entry, claim status and EOB verification
oFollowed up on account collections, denials, Stop Loss, contracts and appeals submissions
oHandled patient and provider customer service for claims resolution of receivables
oCompleted and followed up on accounts receivable collections and accounts payable
oVerified eligibility, benefits, patient and insurance information for appropriate billing
oResearched claims for medical necessity, coding and maximum reimbursement of claims
oReconciled accounts for contract issues, trends, interpretation of agreements and concerns
St Joseph’s and St Helen’s Pediatric Medical Group 02/1996 – 03/1997
Medical Biller
oBilling and follow up on outpatient professional and clinical billing for Commercial, Managed Care
oReviewed and followed up on ICD-9/CPT Coding to ensure appropriate diagnosis and clean claims submission are mailed out to the payors within State/Federal and DMHC timely filing
oHandled Medical/CHDP Transmission, EMC Billing and entered data into computer databases
oPosted payments, adjustments, write offs to accounts for accuracy of contract payments
oContacted all payors for claim status, accounts receivables collections and account payables
oAssisted with educating staff, guiding them on policies and procedures, DMHC protocols
oFollowed up on collections, appeals, pending and aged AR, delays and medical necessity
oRequested necessary documentation, authorizations, medical records and correspondence
oResearched all correspondence, EOBs, Primary/Secondary, Stop Loss billing and verification
EDUCATION:
De Vry University Long Beach, CA
University of Phoenix Gardena, CA
Chaffey Community College Rancho Cucamonga, CA
Watterson College West Covina, CA
SKILLS:
Knowledge of HMO, PPO, POS, MediCare, Medi-Cal, Commercial, Managed Care, Capitation
Full/Shared Risk, DOFR, Contracts/Stop Loss, Examine, Audit, billing and collections
Medical Terminology, Type 50 wpm, data entry, 10 key, ICD9, CPT, HCPC, UB92/HCFA 1500
Medical Manager, E-ZCap, IDX, Facets, Nice, RIMS, SMS, Imaging, Macess, MedMc, MCS, Encoder Pro, Code manager, Virtual Examiner, Lync, work view, OnBase
Windows XP, MS Word, Excel, Power Point, Outlook Express, Internet Explorer
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