Customer Service Medical
Resume:
SHAUNDA SCOTT
*************@*****.***
Shaunda Scott
Hawthorne, Calif. 90250
SKILLS
Specialized training in Customer Service with the ability to seek innovative methods to improve service quality and create efficiency. Extensive experience in team-oriented Special projects. Familiarity with MS Word and Excel, proficiency in Data Entry and 10-Key. Proven skills in research and analytical thinking, problem solving, and conflict Resolution. Self motivated to learn and well organized. 10,077 Key strokes per minute. Type 61 wpm.
EDUCATION
1983-1985 Los Angeles Trade Technical School
400 South Washington Blvd.
Los Angeles, Calif. 90015
Major: Business Education
1982-1983 Los Cerritos College
1111 Alondra Blvd.
Norwalk, Calif. 90650
Major: Business Education
EXPERIENCE
March 17, 2014-present: Senior Claims Compliance Specialist- Healthcare partners Medical Group.
Processing and auditing all professional and facility medical claims, and prepayment audits. Call Health Plans to obtain member's coverage/eligibility, and or benefits. Troubleshoot claims that have been identified as needing additional work in the areas of eligibility,
referral /authorization and contracting or provider set-up. Train and assist other analyst with problem claims. Knowledge of the IDX and Macess systems. Determine is a patient's services are covered, verses non covered. Look up member's benefit plan, member's PCP. View a member's authorization's/referral's, to see is services have been denied or authorized. Work on contracted and non-contracted claims. Make decisions regarding authorization's/referral's from the Care Management/Utilization Management Team. Knowledge of Compliance relate to the processing of claims. 28-30 days for Commercial Claims, and 58-60 days for Senior Claims, (Medical Advantage). Ability to research and verify claims
payment issues. Knowledge of Compliance claims that need to be released in a timely manner. Run Pivot report for all claims received on a daily basis. Run a completed report at the end of the day, for all claims that processed for that day, on a daily basis. Give copy of Error's to the Eligibility Department, Utilization Department, Benefit Department, on different issues that require updating, authorization's that need updated or a referral/benefits that are covered, that has been denied.
January 3, 2006-2013, Claims Benefit Specialist- Advanced Medical Management
Familiar with Medi-care guidelines. Received Certificate That verifies HIPPA Compliant rules. Make calls to Provider’s to verify patient’s benefits and eligibility. Customer Service. Receive calls from Provider’s and Member’s regarding claim status and member’s eligibility. Claim processing and adjudication and claims research on a daily basis. Meet and exceed qualitative and quantitative production standards on a daily basis. Assist Supervisor/Manager with special projects. Support all departments’ initiative in improving overall efficiency. Supports the Supervisor/Manager with reports,
special processes, etc. Interact with other departments and key vendors to resolve claim issues. Perform other duties as assigned. Work on Systems E-Z Cap and OnBase. Knowledge of CPT?HCPC and ICD9 coding, procedures and guidelines. Medical Terminology. Knowledge of Ingenix Encoder Pro. Knowledge of Fee Schedules, Contract Rates, & Per Diem Rates, Timely filing issues and Retro Authorizations on Various Insurances.
June 1997-June 2006, Claims Benefit Specialist, Aetna U.S Healthcare
Review medical and hospital claims to determine the nature of a member’s illness or injury. Determine and understand the coverage provided under a member’s plan. Utilize multiple systems to obtain and record claim information. Data entry. Make payment decisions. Identify claim cost. Work to enhance customer satisfaction and retention. Assist in follow-up training. Assist team member’s in support of achieving team, office, segment and national goals. Lead contact for Coordination of Benefits and Priority claims.
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