Customer Service Medical

SUMMARY

Experienced Customer Service professional along with Medical Billing & Coding knowledge, with extensive and diverse experience in the health care industry.

A well organized, detail and multi-task oriented team player with effective problem solving and communication abilities, Strong multitasking ability to show each member the compassion and empathy needed.

Computer skills include MS Word, Excel, Outlook; proficient with the ASA 400 system, Ez Cap. Phone system: Mitel 5330 IP.

Strengths: Medical Terminology, ICD-9 codes, CPT codes, processing claims and adhering to federal, state and local regulations.

BUSINESS EXPERIENCE

Better Living Now, Hauppauge, NY 04/15-05/15

Insurance Verification (DME)

•Heavy phones averaging between 20-50 call per day from providers verifying members insurance, effective date, type of plan, what is covered & not covered.

•Documentation onto members file.

•Adhere to providers complaints, regarding the authorization or referral process.

•Respond to all claims issues, investigate why claim was not paid, or denied.

•Ensure proper follow up with each provider.

Liberty Health Advantage, Melville, NY 11/10-04/14

Customer Service Rep. (Medicare-Medicaid HMO)

•Respond and investigate to all member inquiries and update each call in members file. Manage and ensure appropriate follow-up and closure to all member inquiries.

• Provide telephone orientations to new and existing Medicare beneficiaries.

• Process and record all member complaints, grievances then submit all information to the grievance department.

• Assist Medicare & Medicaid beneficiaries with the selection and assignment of PCP's, navigate their Rx plan,

Educate customers on what is covered under their plan and how to interpret their ANOC (annual notice of change).

• Update all demographic changes.

• Respond to all claim billing inquiries, from providers and beneficiaries all within HIPPA guidelines.

•Answer several calls per day from CMS (centers for Medicare & Medicaid) during the open enrollment process ).

• Perform retention efforts for all lines of business.

• Handle multi-language Interpreter line on a daily basis

• Handle eligibility Inquiries, benefit inquiries, pharmacy inquiries regarding the formulary, and the OTC benefits.

• Handle disenrollment and enrollment inquiries for all Medicare & Medicaid beneficiaries.

• Assist prospective enrollees with enrollment procedures.

Royal Health Care, Hauppauge, NY 05/05-11/08

Provider Advocate

Provide world-class customer service at the first level of provider complaint resolution by responding to telephone and written inquiries from network providers.

Reviewed, researched and responded to all inquiries from network providers, averaging 50-100 calls daily.

Handle eligibility inquiries, benefit inquiries, claim inquiries, pharmacy inquiries regarding the formulary and the OTC benefits.

Examined and adjudicated insurance claims in compliance with federal, state and local regulations, plan policy and company procedures.

Entered codes and verified dates for computer processing. Analyzed database to identify problems / issues pertaining to claim processing and followed HIPPA guidelines to the fullest extent. Effort resulted in adjudicating past claims.

Worked on special projects for the department in confidentiality. Triaging folders on a daily basis, along with the correspondence department.

Read and interpreted documents, such as medical reports, procedure manuals and complaint correspondence required, leading to effective triaging.

Helped train new employees, covering policy and procedures and instructed on how to utilize required systems.

Emblem (formerly Vytra Healthplan), Melville, NY 07/92-12/04

Customer Service Representative

Investigated and responded to questions from members, providers, hospital representatives, office managers, benefit administrators and employers in a high volume call center in a timely and accurate manner.

Reviewed and investigated issues, regarding claims, benefits and enrollment and billing discrepancies.

Documented accurately all customer service interactions and furnished relevant follow-up correspondence.

Responded to customer and provider correspondence via e-mail or personalized letter

Maintained an excellent record of resolving problems and handling stressful situations with challenging customers.

Proven ability to handle confidential and sensitive information in an appropriate manner.

EDUCATION

Hunter Business School, Medford, NY 03/09/09 Medical Billing and Coding Specialist Diploma

Medical Terminology

Medical Manager

ICD-9 & CPT Coding

Plaza Business Institute, Jackson Heights, NY 08/77-08/78

Completed Business Administrative Diploma Program

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