Customer Service Project

Michele E Calvin

901-***-**** *******.******@*****.***

SUMMARY OF QUALIFICATIONS

Self Motivated Senior Benefit Claims Professional with over 20 years in healthcare commercial and government claims processing; claims training; design & development of training, policies and procedures; strategy project management; corporate and claims auditing; provider & customer service.

Adept in $50,000 - $1 million + large claim review, auditing, processing, and preparation for reinsurance reimbursement

Adept in auditing and savings recovery of $50,000 to $1 million High dollar health claims

Certified in Medical Terminology and CPT-4 Coding. Data Entry keystrokes – 10-13 KPH, Adept in ICD-9, HCPCS, Revenue & DRG coding methodology. Adept in Managed Care Concepts: HIPAA, Fraud & Abuse, HMO, PPO, EPO, POS,, Center for Medicare & Medicaid Services Policy, Managed care Medicare & Medicaid, Dental, Vision & Short Term Disability

Adept in conducting Employee New Hire Benefits, General Orientation, Adept in Project, Workflow and Quality Management

Intermediate user of 2007 Microsoft Office Suite, Adobe Professional, Outlook, and Windows XP; Claims Processing, Patient Billing and Reference Systems: MCS, QNXT, Q-Care, GEMS, Rumba, HSII, Encoder Pro, iHealth, ABF-Emdeon, People Soft, People Safe, Citrix [CE2000], IACS-ECRS, PEGA, HIGLAS [Medicare Accounting System], Medic, Vision

PROFESSIONAL EXPERIENCE

Job Planner, Dexter Solutions, Memphis, TN 03/2015 – 10/2016

Analyze, create printing orders, create jobs and ensure delivered to production within schedule due dates. Collaborate with Account Managers and Manufacturing, and Graphics staff to ensure jobs are exceeding client’s expectations for quality, and timely completion of products requested.

Claims Analyst, Broad Path Healthcare Systems, Telecommute 07/2013 – 9/2014

Staffed for long term projects through Novita, and Health Plan of San Joaquin.

Completion of special projects that assisted in entire Medicare Part B and Medicaid appeals backlog that was over 120 days being reduced to within 30 day requirement, resulted in Center for Medicare & Medicaid Services’ approval, and continuing contract with Novitas and Health Plan of San Joaquin.

Accounts Receivable Representative, Baylor Healthcare Systems, Dallas, TX 12/2011 – 3/2013

Staffed for temporary short term project through Kelly Services.

Created processing workflow and system enhancement that allowed A/R team members to refund over 10,000 unidentified patient accounts, completing project 10 days ahead of deadline.

Analyzed Medicare, Medicaid, Champus/VA, and commercial explanation of benefits to determine under-or over-payments due on over 2500 patient accounts, resulted in 90% reduction of outstanding patient accounts being reduced from over 180 days to 0 days.

Assisted on Project to identify claim over-payments, outstanding credits and debts, and performed adjustment to claims on patient accounts through conversion from Medic to Vision System; resulted in 90% reduction of over 2500 outstanding accounts at 180 days to within 30 days.

Financial Analyst, Broad Path Healthcare Systems, Birmingham, AL 11/2010 – 11/2011

Staffed for long term project through Cahaba GBA.

Hired as Temporary Associate called on to assist in resolving issues, and close out outstanding bulk refund checks over $25,000, resulted in reducing aging refunds from 120 days to within 30 days required time frame.

Applied check refunds, debits, and credits to over 2500 accounts receivables; and insure accounts payable reconciled via HIGLAS and MCS system prior to posting to general ledger within 30 day required time frame.

Interfaced with Center for Medicare & Medicaid Services [CMS via IACS-ECRS system to resolve eligibility records for Medicare beneficiaries.

Operations Trainer/ Senior Claims Benefits Specialist, Aetna, Dallas, TX 1/2000 – 2/2010

Operations Trainer (9/2006-2/2010)

Served as Project lead in the development, design, streamlining and placement of Claims Training, Policy, and Processing Manuals to an on- line retrieval system; resulting in elimination of 95% of E-Mail processing instructions, a 90% increase in claims productivity for entire department, and allowed 14 trainees to immediately contribute to reducing a 50,000 claim backlog that was over 30 days old to 10,000 in 10 days, while maintaining quality far exceeding the 98% financial and 98% procedural accuracy during this time.

Trained, lead and coached contingent claims operations staff [included supervisor, training and auditing staff] to manage claims operations during conversion to new claims processing system for over 2 months. Actions resulted in 0 claims pending in old system when conversion took place.

Assisted Health Plan Corporate Auditor in the review and closure of aged 2008 and 2009 Business Application Management, Provider Information Management System/Network Development, Health Plan, and corporate claims audit issues that were over 180 days old, to within 30 day required deadline within 2 months.

Designed training guide to support the review and resolution of corporate claims audit issues. Managed and directed special project team, which reduced aged-claims audits that were over 180 days old to 30 day requirement in 10 days.

Served as Subject Matter Expert for claims teams with policy, claims processing questions; remote and on-site technical assistance, while supervisors were out of the office; results provided continuity of service to claims operations department, and decreasing calls to our IT desktop support department by over 50%.

Senior Claims Benefits Specialist (9/2000-4/2001, 1/2003-9/2006)

Reviewed and released payment of high dollar HMO Medicaid claims, that exceed Benefit Specialist’s adjudication authority [$10,000 - $1 million+] or processing expertise via GEMS and QNXT systems; while consistently exceeding 98% financial and procedural accuracy, and production standards by over 135%.

In 2004 maintained 100% Financial and Procedural accuracy for 11 consecutive months on High $50,000 to $1 million+ claims, Inpatient Facility, reconsiderations and appeal claims; resulted in increase approval rating from the Health Plan - Client.

Consistently achieved and exceeded standard 98% financial and procedural quality, and exceed production standard by over 135% ratings to attain company bonuses from 2000-2001 and 2003-2006.

Trained and Mentored Senior Analyst on Medicaid policies for Inpatient Hospital, professional high dollar, and adjustment to claims, processing guidelines, and workflow distribution; results enabled the Analysts to exceed production standards by over 125%, and 98 % financial and procedural quality standards, thus immediately responding to operation needs of their unit.

Made outbound calls to obtain required information for First claim or re-consideration; resolved issues from providers and ensured that claims are handled according to Medicaid guidelines.

Managed distribution and work assignment backlog of High Dollar, Inpatient Hospital claims, Reconsiderations and Appeals, for Senior Analyst department; this allow the Supervisor to concentrate on managing other departments, and to keep Senior Analyst’s policies updated.

Primary Senior Analyst responsible for high dollar stop loss claims referrals; collaborated with Finance Accountant to make sure that member’s eligibility was current, all claim payments were accurate, made adjustments as required, and compiled documentation needed to send to reinsurance carrier. This allowed Accountant to expedite cases to Reinsurance Company, and ensured prompt reimbursement to the health plan for claims over $100,000.

EDUCATION

Baylor University, Waco, TX - 102 hours of credit

Ashford University – BA in Health Care Administration, Health Informatics in progress, Sept – Dec 2014 -4.0 GPA

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