Customer Service Quality Assurance

Aunqueta E. Wise

**** ******* ****** *** ******: 904-***-****

Jacksonville, FL 32217 Email: ad1ims@r.postjobfree.com

Summary

Dependable and professional Medical Claims Processor with 20 + years' experience in processing and coding claims, while ensuring all criteria are met before eligible payments go out. Ability to work with multiple clients while monitoring insurance billing changes. Highlights

• Proficient in insurance procedures

• Auditing for overpayments

• Claims adjustment

• Funds recovery

• Quality assurance

• Able to work as part of a team or individually.

Professional Experience

2022-2023 Health Axis

Claims Examiner

• Interpret and apply specific plan document language determine eligibility for benefits during claims adjudication.

• Provide responsive and professional customer service for assigned groups other groups with Client as needed.

• Processed complex claims requiring further investigation, including coordination of benefits, and resolving pended claims.

• Review and compare information in computer systems and apply proper codes/documentation.

• Placed outgoing calls to providers and/or pharmacies for further investigation before processing claims.

• Complied with all quality control standards set by the company for the handling of claims. 2000- 2021 Florida Blue (Previously Blue Cross and Blue Shield of Florida) Employee Service Advocate for Retail Store

Claims Adjustor and Analyst

• Processed assigned claims.

• Investigate claims for possible fraud.

• Review and adjudicate high-risk claims.

• Inspect claims for proper allocation of co-pays, co-insurance, and deductibles.

• Trained to handle third party liability.

• Responsible for disability, medical, and death claims processing.

• Paid and processed claims within designated authority levels.

• Ensured claim investigations are timely and appropriate, and that decisions are correct.

• Conduct regular audits of random claims for purposes of quality assurance.

• Investigate overpayments and funds requirements.

• Processed policy changes on individual health policies.

• Proficient with claim processing software: Convergence, Client Letter, Siebel, Enterprise Image Processing (EIP), Intranet Contract Benefits (ICB), Corporate Medical Clearance Application

(CMCA), and the Diamond Platform.

• Maintained knowledge of policy and procedures and insurance coverage benefits levels, eligibility systems, and verification processes.

• Crossed trained to assist and handle status calls in the call center.

• Handle internal and external customer’s telephone and written inquiries regarding billing and claims processing.

• Demonstrated timely customer service and cross-functional coordination of account information to promote and maintain positive customer service.

• Performed patient billing and collection activity as a result of patient contact via telephone.

• Responsible for zeroing out inventory daily.

• Handled written and phone inquiries related to claims and benefits.

• Maintained strict compliance with related policies and procedures in all transactions, ensuring the protection of patient's Protected Health Information. Competencies

• Insurance claims processing

• Data security procedures

• Thorough claims review

• Health insurance industry knowledge

• Medical terms and procedure knowledge

• Telephone etiquette

• Maintained 100% quality score

EDUCATION

Americus High School

Americus, Georgia

High School Diploma

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