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Customer Service Representative

Baltimore, MD
July 01, 2016

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**** ****** ******

Baltimore, Maryland 21239

Home: 443-***-**** Business: 443-***-****


To obtain a challenging position which will enable me to utilize my customer service and healthcare administration experience, communications and interpersonal skills.


Morgan State University, Baltimore, Maryland

Community College of Baltimore, Baltimore, Maryland

Technical Skills/ System Platforms

Microsoft Office (Word, Excel, Power Point) Outlook, SharePoint, Facets, Marx, Burgess, McKesson, On Base, ICD-9 Coding,

CPT Coding, HCPCS, Medical Terminology, HCFA


Appeals Representative- United Healthcare (March 2015- March 2016)

Responsible for reviewing researching, investigating Medicaid cases for the following states Texas, Washington and New York, and triaging all types of appeals and grievances. Communicates with appropriate parties regarding appeals and grievance issues Primary Responsibilities are to ensure complaint has been categorized correctly while determining and confirming member eligibility and benefits. Initiate outbound contact to members or providers. I obtain additional documentation required for case review and place relevant documents into image repository. Cases must be reviewed to determine if clinician review is required, render decision for non-clinical complaints using sound, fact-based decision making. Research and resolve written complaints submitted by consumers and physicians/providers, draft verbiage for use in outbound correspondence, prioritize and organize tasks to meet compliance deadlines while meeting established productivity schedule adherence and quality standards

Claims Analyst – Xlhealth (March 2008- March 2015)

Health provides exceptional disease management and wellness support services to chronically ill patients and their physicians, as well as to health plan providers and government entities. Our services and expertise cover a broad range of related conditions, including: Diabetes, Congestive Heart Failure (CHF), Cardiovascular Disease (CVD), End Stage Renal Disease (ESRD), and Chronic Kidney Disease (CKD).

I am responsible for conducting the monthly accuracy audit on the outside claims vendor used to process the claims volume. As a recovery analyst I review claims payment inquiries from providers and members and adjust for additional payment or retract overpayments in Facets System. Communicate to the member services, provider services and compliance division the results of the research by documenting Share Point Data Center. Analyze pended claim trends to determine any necessary refinement of business rules and workflow in order to improve the overall claims process. I also work on special projects ranging from auditing to payment recoveries. Utilize the CMS (Medicare System) to review and price claims- Ambulatory Surgical Centers, Durable Medical Equipment, Out-Patient, In-Patient, Home Healthcare and Professional claims according to CMS guidelines and regulations.

Claims Analyst - Bravo Health (July 2007- March 2008)

In this position, I was responsible for processing claims for members on Medicare. Payment is made to providers of care for services rendered in an office setting, emergency room, skilled nursing facility, laboratory, Durable Medical Equipment and many other facilities. The process is one that is performed manually. Calculations must be made to apply the correct co-payments, coinsurances and deductibles. Research is also necessary for correct benefit applications.


1339 Walker Avenue

Baltimore, Maryland 21239

Home: 410-***-**** Business: 443-***-****

Claims Processor III - CareFirst Blue Cross and Blue Shield of Maryland (Feb 1993 –Sept 2000) (Jan 2001-July 2007)

Responsible for the timely and accurate adjudication of all claim types for two of the largest accounts in the corporation. The State of Maryland and The City of Baltimore. As a claims and service representative, I am able to meet or exceed company goals and expectations individually while supporting and maintaining a strong team concept. I also accepted the responsibility of interacting with the various Medical Sites and Freestate (HMO) to adjudicate the Blue Plus Opt Out and Choice Advantage products. I responded to phone calls of providers and subscribers that included updating customer inquiry files and insure the completion of adjustments. This is achieved by using my strong written and verbal communication skills, problem solving skills and effective interpersonal skills.

Business Analyst - Carefirst Blue Cross Blue Shield of Maryland (Sept 2000- Dec 2000)

My role as a Business Analyst I provided ongoing, internal and external customer support by advising business units of business system planning and organizational development; prepare proposals and business improvement recommendations. Performed Planned, conducted and coordinated systems integration and quality assurance related activities to include: project definitions and planning requirements, workflow, test system maintenance production monitoring-Business support responsibilities to include production monitoring, file maintenance, ad hoc reporting and consultation with internal and external users. Researched and analyzed system problems tracking resolution, documented and communicated alternative workarounds for system defects until system solutions could be implemented. Collaborated with peers in the development of user documentation and training for system implementations and enhancements. Performed team administrative duties status reporting, team development- self/peer/project assessment.

Claims Specialist/ B.U.R.T.Team Rep. - Blue Cross and Blue Shield of Maryland (August 1981 – Jan 1993)

As a claims specialist, I was responsible for the timely and accurate adjudication of inpatient hospital bills manually and via CRT. Corresponded with hospital accounts directly through computer network; investigated and resolved errors. Handled discrepancies and client problems, answering service requests from other departments and assisted with the training of new claims specialist. As a result of my abilities adjudicating claims I became a member of the Business Unit Response Team (B.U.R.T.). In this position, I provided support during an ongoing conversion of computerized claims examination systems for various internal departments. Responsibilities included processing claims for non-traditional products during individual unit conversions, training personnel, system testing, problem identification and verification of system corrections and BIDS records. I also served as the user advocate regarding system design/functionality and developed performance agreements with clients.

Senior Claims Specialist FreeState Health Plan (April 1987 – May 1990)

Primary responsibilities included adjudicating HMO claims to determine company liability, reviewed, resolved and encoded claims. I processed adjustments to correct payment errors as well as investigated and resolved problem claims presented by HMO members, physicians and facilities. I prepared written correspondence and responded to client/provider telephone inquires regarding coverage and benefits. I was assigned as the specialist handling questions of team members.

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