Customer Service Medical
Resume:
Maudtrice D. Ward (Resume')
PO BOX ****** Houston, TX 77244 Cell # 713-***-****; ********@*****.*** or *********@*****.***
SUMMARY OF QUALIFICATIONS
Well trained, self-starter with call center environment experience
Specialist and Manage Care Provider Relations Representative (Health Plan)
Medical Coding experience and accounting
Plan, develop and direct programs, services, activities and employees of the agency and consistency with company policies, accountable for agency revenue, and profit performance
Adhere to company systems and compliance with State and Federal regulations
Excellent verbal, written and interpersonal skills
Balancing daily deposits and spreadsheets for clients
Daily research and resolution of discrepancies
Processing client refunds
Balancing daily reports and backup
Filing and archiving
10-key by touch
PROFESSIONAL BACKGROUND Imedgroup/US Anesthesiology Coding/Billing Specialist/Call Center Environment
05/2013 to 10/2013 713-***-**** Part-time
Coding Compliance - Identifies unbundled procedures according to CPT guidelines and current Medicare NCCI rules. Identifies other coding related denials including medical necessity and modifier usage. Provides feedback to physicians and management staff regarding denials.
Coding of records for reimbursement and DRG
Assign codes to categorize diagnoses and procedures. Based on the classifications, healthcare providers assess the reimbursement.
Work with other state, local or private agencies that are affected by cost containment policy changes
Universal American Inc/Heritage Cost Containment Specialist/Call Center Environment
10/2010 to 09/2012 713-***-**** Part-time
Ensure proper documentation of patients' medical histories
Medical Coding for DRG reimbursement
Categorize diagnoses and procedures. Based on the classifications, healthcare providers assess the reimbursement
Serves as department's technical expert in the highly complex areas of health care cost containment
Provides technical expertise to other divisions, within the department, in the areas of policy development, research and evaluation, reimbursement methodologies and health care cost containment initiative
Analyzes reports and documents from federal, state and the department and recommends cost containment policy changes
Prepares annual legislative Health Care Cost Containment Report which outlines the department activities in this area
Keeps abreast of legislative and technical developments and change related to the area
Works with other state, local or private agencies that are affected by cost containment policy changes
United Healthcare Provider Relations Representative/Appeals & Resolution
7/2003 to 10/2013 713-***-**** Full-time
Develop strong interpersonal relationships with providers. Strengthen and enhance the role of the provider relations representative with providers.
Superior customer service skills and a commitment to timely resolution of customer issues.
Perform great under pressure and meet deadlines. Strong organizational, time and management skills with the ability to manage multiple projects. Self-starter with ability to work independently with minimal supervision and collaboratively within a team environment
Helps customers with applications and services in order to find providers that meet their needs
Data entry and communication with internal and external customers
Interactions are high volume via phone and/or other virtual communication methods.
Develop and maintain effective working relationship with claims department, member services, medical management and sales and marketing departments
Negotiate fee schedules and contracts with providers
Utilize software systems and databases to provide reports on activities to network administrator. Assure that all responsibilities are performed consistent with the deliberate plans of the organization
Medical Recovery Specialist/Call Center Environment
Represent the organization at all times; support its mission, goals and objectives; participate as a "team player", constantly supporting other managers; set an example of high personal and professional conduct for employees and others. Maintain personal professional development
Efficiently navigate claim processing systems (Unite, Cosmos, RealMed, Prime, Comet, Facets and other systems as appropriate) to complete claims and simple adjustments from an immediate customer request
Handling complex claims resolutions
Fast and accurate problem identification
Wellpoint/BCBS of California Provider Relations Representative/Call Center Environment
04/2001 to 5/2003 317-***-****
Responsible for coordination of managed care applications, provider/member claims and review of managed care contracts
Problem solving skills with the ability to identify and evaluate problems.
Excellent verbal, written and interpersonal skills
Interacts with physicians, medical office staff and health plan representatives. Travels within Wellpoint/BCBS facilities
Houston Hand and Upper Extremity Electronic Medical Records Coding Specialist
01/1997 to 04/2001
Assign codes to categorize diagnoses and procedures based on the classifications of health care providers assess the reimbursement
Coding of records for reimbursement and DRG
RMI(Radiology Management Imaging) Patient Account Billing Supervisor
05/1995 to 01/1997
Accounting functions including posting daily receipts into both the financial accounting and patient accounting systems
Reconciling total postings to total receipts. Auditing remittance advice received from the bank
Managing the edit and rejection lists for charges entered working with 3rd party payers and patients to collect unpaid balances and managing the overall Age trial Balance for the business locations as assigned and other duties as assigned
Worker Comp, Medicare and Medicaid posting run reports and complete monthly productivity analysis for all employees in payments department
Nylcare/Aetna Ins Company Claims Analyst/Customer Service Supervisor/Call Center Environment
03/1985 to 1995
Use broad knowledge of medical terminology, COB, Medicare, CPT coding, ICD-9, HIAA coding. Medicare/Medicaid, HMO/PPO, Commercial, Worker Comp and DME insurance to ensure validity of claims. Grievance and Appeals.
One of the company's top producers, consistently achieving highest quality
Research investigates and process complex claims in time manner
Assist in training and auditing
Work directly with agents and insurance representatives
Updated training and auditing procedures to address claims-processing concerns
Trusted with high dollar claims issues limitations for release of payments to providers
Paying a DRG case rate when the system processed the claim using daily room charges.
Proficient with the system's eligibility, authorization, and claim modules. Consider all patients, health plan, and contract terms received as confidential. Demonstrate an active interest in improving current level of skill and knowledge
EDUCATION University of Phoenix - 09/2012 Bachelors Healthcare Administration w/Health Information System
COMPUTER SKILLS
Operating Systems: FACETS, CMS system, Encoder, Windows, Mac, Health Quest, Med Soft, RealMed, Cosmos, Med Host
Applications: Excel, WordPerfect, Word, NexGen, Medic, Versys, PowerPoint, Cosmos, Diamond, FACETS, Citrix, IDT, IBAAG, UNET, KNOWLEDGE LIBRARY, AND VOICEDOC, ICD-9, CPT CODING
KEYWORDS: Cost Containment Specialist, Provider Relations Representative, Health Care Administrative, Supervisor, Medical Claims Analyst, Claims Investigator, HMO & PPO, Worker Compensation & Third Party
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