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Customer Service Medical

Location:
Orange, California, 92868, United States
Salary:
50000
Posted:
December 24, 2015

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Resume:

PHILIP E. STERLING

P.O. Box ***

Orange, CA *****

714-***-**** cell

714-***-**** message

acswm5@r.postjobfree.com

PROFESSIONAL SKILL SET/SOFTWARE USED

Working knowledge of ICD-9, Trained in ICD-10 in 2013/2014, CPT, revenue,

& procedure codes on CMS1500, and UB-04 insurance forms using Next Gen,

Office Ally, Medical Manager, Allscripts, eBridge, Epic, Capario, HMS,

Xifin 5.5, NetSuite, Sage Intergy, Citrix, Meditech, & Microsoft Word

PROFESSIONAL MEDICAL INSURANCE HIGHLIGHTS

Various Temporary Positions, Orange County CA 03-2011 to PRESENT

I was assigned as a Certified Medical Coder[ICD-9 & CPT]/Collector/Workers Compensation Claims Reviewer/State Reporting Auditor/Patient Account Representative, and Claims Examiner.

Reviewed UB-92/UB-04, & HCFA 1500 claims for accuracy prior to submission.

Contacted providers by phone, or fax for coding/procedure clarification on requisition questions.

Made outgoing calls to insurance companies to verify receipt of insurance claims.

Corrected claims that was denied for errors and re-billed claims with attached information.

Received calls from patients regarding their outstanding balances.

Generated patient statements for co-payments, co-insurance, and deductable due amounts.

Follow-Up on EOBs and insurance correspondence such as non-payments, and underpayments.

Manpower Staffing Agency [Assigned to Lab Corp, d/b/a LabWest], Orange CA 08-2010 to 03-2011

Medical Coder/Sr. Medical Coder II

Assigned ICD-9 (diagnosis) codes to 300+ claims per day for government insurance submission (Medicare/Medi-Cal), and commercial insurances.

Requested additional information from the lab technicians for patient treatment clarification.

MedAssist/First Source, Louisville KY [worked remotely from] Orange, CA 11-09 to 8-2010

Patient Account Representative /Auditor & Biller/Collector/Claims Examiner & Follow-up/Insurance Verifier

Bloomington Hospital in Indiana outsourced their billing and accounting department to MedAssist of whose patient accounts I was assigned.

Contacted insurance carriers to verify hospital claim status for outsourcing clients. Billed hospital claims (Medicare and Medicaid) with corrected information obtained by web, phone, or fax.

Audited physician claims for proper billing, coding, and adjudication, conducted audit meeting with physicians and their staff on a monthly basis.

CHOC [Children’s Hospital of Orange County], Orange CA 5-09 to 10-09

Patient Account Representative: Endocrinology and Metabolic Specialist Collector/Insurance Verifier

Responsible for reviewing A/R reports such as non-payment EOBs, no response claims list, and denials to expedite claims payment. Insurance payers were contacted (Medicare/Medi-Cal, and commercial insurances), by phone or fax, to check claims’ status. Rebilled corrected Endocrinology physician claims in a production environment.

Worked within CalOptima/CCS/Medi-Cal and Medicare guidelines, and commercial carriers.

Received calls from patients and insurance companies regarding their accounts, updated insurance information, retrieved medical records.

From insurance companies, calls were received to complete their files on medical records and additions to their family coverage, both primary and secondary coverage’s.

Recorded, and edited training modules for the Human Resources Department.

Tristar Insurance Group (Coventry-First Health)(CSSI Temp Division), Santa Ana CA 2-07 to 3-09

Certified Coder II /Sr. Technical Billing Analyst/Claims Auditor/Sr. Technical Claims Specialist

Reviewed, audited, coded and re-coded up to 150 workers’ compensation physician, hospital, legal/QME insurance injury claims and prescription invoices for claims examiner final payment offer and complete claim adjudication.

Handled high dollar and complex liability injury claims for physical pain and related legal costs.

Contracted/Temporary Positions, Orange County/Ventura County, CA 06-04 to 02-07

Humana Health Insurance, Louisville KY 2-91 to 5-04

Coder/Outbound Call Center Supervisor/Claims Correction Supervisor/Medical Claims Specialist,

Examiner & Analyst/Classroom & Floor Trainer/Claims Verifier & Auditor/Media Announcer

Processed HMO, commercial, Medicare HMO, and Medicare Supplemental insurance claims on both HCFA, and UB92s in a production environment, often exceeding 250 claims per day.

Resolved quality control issues by correcting billing errors on submitted physician and hospital claims in the Medicare, and Medicare HMO units.

Initiated calls to providers, regarding on-going billing errors and worked together to resolve claims issues for clearer accuracy and faster payment processing.

Supervised the Outbound Call Center within the Medicare Department, up to five employees.

Assisted the call center on in-bound physician calls regarding claims payment issues.

Worked with managers and supervisors to implement and improve training programs.

Co-taught Claims Examiner/Adjuster classes and created classroom material for each class. Developed and taught classroom materials to assist in preparing the newly hired claims examiners/adjusters and customer service associates after training.

Gathered evidence for on-going fraud investigations on selected providers.

Voiced training videos at the Humana studios for the scanning and training projects.

CREDENTIALS AND EDUCATION

CPC Certified as a Coding Professional since 2010

Red Cross Certified in CPR/AED/First Aid for adults and pediatric victims

Scored 93% on the California Bill Review [Workers Compensation] exam

Jefferson Community College, Louisville KY Major: Business Administration

Santa Ana Community College, Santa Ana CA, Journalism/Liberal Arts Major

SUMMARY

Medical Terminology Certified

Licensed and certified forklift driver

Outbound call center supervisory experience

Professionally trained in ICD-10 through AAPC

Experienced in Government & Commercial billing

Supervisory experience in the broadcast/media industry

Supervisory experience in the medical products industry

Knowledgeable of ICD-9, HCPCS and CPT coding principles

Experienced in Government & Commercial claims processing

Supervisory experience in the interstate transportation industry

Experienced in Government & Commercial account collections

2007-2008 Volunteer/Non-Native Planet Eradication Project, Channel Islands Restoration,

Anacapa Island, Ventura Office, and Santa Cruz Island, Santa Barbara Office

2008-2010 Volunteer/Restoration Project, Nature Conservancy side of Santa Cruz Island

*When not temporarily employed, I volunteered as a Food Pantry Worker with a non-profit food distributor in downtown Orange. I was also the Toys for Tots Local Christmas Co-Coordinator Orange County 2005-2013.

VOLUNTEER CITY ENFORCEMENT

City of Orange Police Department, Citizens Police Academy

Dispatch Training by Observation May-June 2015

Crime Control, Crime Occurrence stats. Peace Officer qualifications, Crime Investigation Matrix, K-9 Training, Ride-Along Program, Partnership between city and county governments, job fairs.

City of Orange Police CERT Training Oct-Nov 2015

(Community Emergency Response Team)

Disaster Preparedness, Terrorism, fire safety and utility controls, disaster medical operations

Search & Rescue Operations, cert organization, Disaster Psychology.



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