OBJECTIVE:

To obtain a position that offers opportunities to use my

extensive knowledge and skills.

EXPERIENCE:

****-*******

CENTENE CORP.

Referral Specialist

Tempe, AZ

• Assist in monitoring utilization of medical services to assure cost effective use of medical resources through processing prior authorizations.

• Initiate authorization requests for outpatient and inpatient services in accordance with the prior

authorization list. Route to appropriate staff when needed.

• Verify eligibility and benefits

• Process faxes within established standards

• Data enters authorizations into the system.

2017-2019

CENTENE CORP.

Claims Analyst

Tempe, AZ

• Process pended medical claims, verifying and updating information on submitted claims and reviewing work processes to determine reimbursement eligibility. Ensure payments and/or denials are made in accordance with company practices and procedures.

• Apply policy and provider contract provisions to determine if claim is payable, if additional information is needed, or if claim should be denied. Claims processing may be related to physician and hospital services, coordination of benefits

(COB), high dollar, special pricing, refunds and/or adjustments on resubmitted claims.

• Research and determine status of medical related claims

• Review charges, access the computer system and use payment or denial codes within established department guidelines and standards

Shatarra

N.Jones

5143 W WESTERN STAR

BLVD.

Laveen, AZ, 85339

480-***-****

ad1oci@r.postjobfree.com

Page 2

• Clarify health insurance coverage for coordination of benefits to process claims

• Maintain records, files, and documentation as appropriate

• Meet department production and quality standards 2017

Computer Share

Customer Service Representative

Tempe, AZ

• Responsible for handling inbound and outbound calls up to 15 days past due with a priority of Welcome Calls,

• Payment Inquiries,

• Account balance information,

• Document Request, Year-End information,

• Payment Methods,

• Web Assistance, establish ACH.

• In addition the Customer Care Associate I may be assigned other duties based upon the needs of the business. 2016-2017

Southwest Diagnostic

Patient Care Coordinator

Phoenix, AZ

• Handled inbound and outbound calls

• Performed insurance verification

• Handled billing

• Assisted with collections operations

2016

Option 1 Nutrition

Patient Care Coordinator

Chandler, AZ

• Performed intake for DME services.

• Handled inbound and outbound phone inquiries.

• Verified insurance, authorizations, and clinical documentation for accuracy.

Page 3

2016

Optum Rx

Pharmacy Technician

Phoenix, AZ

• Respond to incoming calls from our customers on

issues related to benefit eligibility questions and prescription status inquiries

• Guide and educate callers on their prescription

benefits, use of plan, formulary, premiums and status of orders and claims or inquiries

• Ask appropriate questions and listen actively while documenting required information in computer

systems

• Identify issues and communicate solutions and steps to customers, pharmacies and physicians with

prescription orders and reorders

• Make outbound calls to customers on prescription orders and payment issues

• Managed prior authorizations for pharmacy services

• Followed up on clinical information

2015

Tri West Healthcare Alliance

Customer Service Rep

Phoenix, AZ

• Utilizes various software applications in use at TriWest.

• Understands procedures and processes of the VA

program.

• Performs claims research, including interpreting VA policies, investigating automated transactions,

documenting outcomes, updating records and

reporting accurately on research findings.

• Resolves incorrect claims processing, calls providers for Missing claims and medical documentation to

resolve Veteran billing issues.

• Reviews authorizations to establish ancillary providers associated and obtain claims missing for payment.

• Answers inbound calls from Veterans and providers in a timely manner. Makes outbound calls to resolve

Veteran billing issues.

• Consistently displays professional and courteous service skills to internal and external customers.

• Responds to inquiries from Veterans and providers regarding specific aspects of the VA program.

Page 4

Information and assistance includes providing details about referrals, authorizations, and claim status and billing discrepancies.

• Protects the privacy of health information of patients when using or disclosing Protected Health Information

(PHI). PHI is any information about health status, or healthcare services that is linked to an individual.

• Takes appropriate measures to comply with HIPAA

regulations to protect privacy of beneficiaries' health information Documents all communications involving Veteran and provider contacts.

• Coordinates complete resolution of service issues by interfacing with the TriWest Complaints & Grievance Specialist and other departments.

• Understands and utilizes the grievances and appeals process available to dissatisfied beneficiaries and providers.

• Consistently meets department productivity and

performance metrics.

• Performs other duties as assigned.

2010-2014

Banner Health

Central Intake Rep

Phoenix, AZ

• Handled all incoming calls pertaining to referrals, refills, request for services, and follow-ups. Initiated insurance verification and gathered all information necessary for pre-certification.

• Ensured each patient met admission criteria and

followed patient through to discharge.

• Assisted patients with benefits and insurance plan details.

• Enrolled new employees and existing employees in company provided benefit plan.

• Handled appeals and reconsiderations for claims for multiple insurance carriers.

Page 5

EDUCATION:

1997

FORENSIC SCIENCE

GRAND CANYON UNIVERSITY

1993-1997

General Studies

South Mountain High School

References are Available upon Request.

Contact this candidate