Medical Customer Service
Resume:
AMA T. CALAGUI
*** ********** ***. ***# *** • WEST SACRAMENTO, CA 95605
PHONE 916-***-**** • E-MAIL **********@*******.***
Objective Conscientious business professional with experience in medical claims processing, office administration and retail sales. Personable, team oriented and committed to providing top-quality work to meet company goals.
Education General Education 56 units October 2009
Merritt College – Oakland, CA
High School Diploma June 1996
Skyline High School – Oakland CA
Knowledge Exceptional interpersonal communication skills
& Abilities Positive attitude and strong work ethic
Possess strong organizational skills
Effective paper claim processing techniques
Resourceful and adaptable to any office environment
Proficient in Microsoft Office applications
Type 50 WPM,
10-key by touch,
Accurate maintenance of files/records
Knowledgeable of medical terminology
Excellent attendance and punctuality
HIPPA Certified
Professional Claims Adjustor – Correctcare Integrated Health (2014 - Present)
Experience Process payment/denial of medical claims, using the WLT claims processing system
Assure claims are adjudicated within the designated timeframe
Meet productivity and expectations on a daily basis.
Respond to customer inquires
Research and request information regarding payment of claims
Perform various duties assigned by management
Have professional work ethics
Reliable attendance and punctuality.
Claims Processor II – Zenith American Solutions-Coastwise Claims Office (2012 – 2013)
Processes rand rout medical and hospital claims to the correct claim specialist
Consistently meets performance standards, including quantity and quality claims processing standards
Assist customers with questions and inquiry of claim status
Request additional information from providers and members when necessary
Current knowledge of assigned Plan(s) and effectively applies knowledge in the payment of claims
Assist claims supervisor with special assignments or projects
Assists with customer service by responding and documenting telephone/written inquiries regarding eligibility, benefits or claims status; setting up claims to be re-opened; and processing check tracers
Claims Examiner – Cigna Corporation (2010 - 2012)
Review/process medical claims for occupational, physical therapy, surgery, mental health, and office visits
Utilize product and system knowledge to accurately and efficiently process claims
Research and analyze claims accurately to avoid processing errors
Insure accurate benefit plan calculations for major medical expenses and deductibles
Quality metrics achieved with 98% Financial, 92% Payment, and 93% Procedural accuracy
Compliant in meeting guidelines set by quality coaches for questions and coaching
Process total claims at 16,802 or 391 claims per week and meet benefit payment requirements within 14 days.
References Upon Request
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