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

#***

Omaha, NE *****

Phone 402-***-****

E-mail

ad2m4d@r.postjobfree.com

Jeffrey D Nelson

Objective

To obtain a position with higher level of responsibilities which will effectively utilize my experience while providing an opportunity for personal and professional growth within the company. Work Experience

BayMark Services Inc. Omaha, NE

May 2022 to May 2023

Fiscal Clerk

This position performs a variety of complex clerical and accounting functions for patient billing, including verification of invoice information, maintenance of third party billing records, and resolution of a variety of problems. Follows up on submitted claims and patient billing; resubmits claims or resolves problems. Handle cash items and accounts receivable posting. Perform administrative functions and assist with the coordination of office activates under the supervision of the Treatment Center Director. Maintain the paper flow of clerical functions in the office.

Review, maintain, and process fiscal/account records and transactions related to patient’s accounts. Verify insurance benefits and billing information by terminal and/or telephone. Annotate accounts with insurance coverage and estimated patient shares.

Contact third party payers (insurance providers and state/federal agencies) for payment cost billing. Resolve issues with payment and billing, authorization process. Forward information as appropriate to expedite payment.

Maintain accurate accounts, i.e. required signatures, proper account annotation, current demographics and correspondence.

Insure completion of pre-authorization process inquiry and referral to clinician. Monitor insurance authorization and claim rejections.

Maintains fiscal records and/or worksheets for all calculations, extensions, and verifications related to record keeping for assigned patient’s accounts.

Perform tasks consistent with authorization and billing requirements. Maintain concurrent authorizations as needed. Contact patients for payment of account or payment arrangements according to current policy. Prepare weekly production logs for self-pay clients. Track self-pay balances. Prepare self-pay detox list.

Prepare late notices for delinquent accounts.

Maintain confidentiality of patient records.

Respond appropriately to request for information regarding accounts from payer, attorney, and others.

Track/monitor authorizations from insurance company/third party.

Ability to handle stressful situations and interact with others. Ability for in person meetings and access to a computer without violating company policies.

Builds blank patient files for new admissions.

Assists in obtaining and following up on patient histories from the NTP’s

Backup Receptionist as needed by: Checking in patients, collecting payments, answering phones, scheduling intakes, and data entry.

Reconcile daily money collected.

Assist with archiving discharged files, including archiving

Conduct follow up calls.

Assist with various administrative duties, as needed by treatment Center Director.

Checks insurance eligibility, when applicable.

Support organizational and departmental philosophies, goals, and objectives and through own behavior leads and motivate others to do so.

Keeps appropriate records as required by Company protocol and Federal and State Regulations.

Other duties as assigned.

Multiplan Omaha, NE

August 2016 to September 2020

Claim Review Analyst

This position assists management by performing reviews and validation on individual claims that do not auto adjudicate and/or receive a recommended reimbursement amount.

Evaluate claims that do not auto-price in the system. Review incoming claims using policy and procedure guidelines. Escalate issues not covered within guidelines for management review.

Identify issues and make necessary corrections to the claim in order to obtain a reimbursement amount when/if available. Make appropriate inquiries to clients and/or providers to obtain missing information.

Review correct and/or non-conforming claim. Confirm corrected claim will process or verify results of calculations for uncommon or uncharacteristic claims.

Make recommendations on efficiencies to department policies and process

Assist with special projects when needed.

Collaborate, coordinate, and communicate across disciplines and departments.

Ensure compliance with HIPAA regulations and requirements.

Demonstrate Company’s Core Competencies and values held within.

The role was considered to be High Risk Role because of Sensitive Data. Aetna Better Health Omaha, NE

September 2014 to January 2016

Provider Relations Representative

This position was direct relations with Providers in Aetna Better Health Medicaid Business. Providers were assigned by county and Delegated Credentialing Entities. My accountabilities include:

Assist providers with claim issues, create projects to reprocess claims with system issues.

Attend conferences to speak about Aetna’s products and services available to them

Any contract related issue’s would be reviewed and fixed by me, by way of forms to update Aetna’s system.

Frequently do site visits to discuss any issue’s or concerns related to Aetna Better health

Prime Therapeutics St Paul, MN

2005 to 2013

Medicare Part D Reprocessing Analyst

This position is a subject Matter expert for Medicare Part D claims, TrOOP and Drug spend accumulation activities for the Government Programs Membership Management department. My accountabilities include:

- Research issues and analyze claims to ensure proper claims adjudication is performed. Verify TrOOP and Drug Spend balances are calculated accurately and accumulate in accordance with the member’s benefit in the appropriate Medicare Part D phase.

- Review, test and provide feedback on claim adjudication system upgrades and ad-hoc testing for TrOOP and Drug spend activities.

- Analyze reports and information received to identify the need for retro-eligibility reprocessing of claims.

- Subject Matter Expert for cross-functional projects on TrOOP and drug spend accumulations. Actively participate in workgroups and attend planning meetings. Member Service Agent 2005-2006

This position is in relation to the contact center receiving customer service calls from BCBS members. My duties are to effectively look up claim status, order status, answering questions relating to members pharmacy plan coverage and placing order refills online. I have utilized company applications such as PCT, BET, AS400 with effective knowledge and speed. Asked to work on a top company project for 1 months in Richmond, VA. Taking part in a special team project (SWAT TEAM) to be a subject matter expert for our vendors training customer service representatives for Medicare part D. This is noted to display my flexibility at a moments notice to better service Primetherapeutics in any way.

Midlands Choice Omaha, NE

2002 - 2005

Senior Flex Plan Administrator / Flex Plan Administrator / Repricing Specialist Senior Flex Plan Administrator:

After six months I was promoted to Senior Flex Plan Administrator. These duties included supervision of the 3 current flex plan administrators for attendance and quality of service being relayed back to our groups. This position also required me to run live checks every Wednesday to be mailed or sent by EFT to our members for payment. I would also take over any escalation of service matters that was brought up by our groups through their benefit coordinators. I would run monthly and quarterly reports to our members and benefit coordinators, and make changes to their SPD (standard plan documents) when needed. Many occasions this entitled me as well as our marketing department to go out in the field to our current and prospective clients for open enrollment.

Flex Plan Administrator:

I was promoted after six months to flex plan administrator for the third party administrator (midlands benefit administrators) side of the company. This position was a customer service/accounting position that worked under the IRS 125 cafeteria plan. My duties included claims adjudication and payout; customer service calls, reconciling monthly check contributions. I mastered dos/as400 systems we used, and became proficient in Microsoft word and excel spreadsheet. Repricing Specialist:

This position started out for me as a repricing specialist for the PPO network side of the company. This was a direct data entry and claims processing position. Along with this position I was assigned quality control to all claims being repriced to make assurance through reports to management that this was being done correctly.

World Insurance Omaha, NE 2001-2002

Customer Service Rep

This position was an inbound/outbound insurance customer service. Duties included taking calls from providers relating to claims status, benefits for in or out patient stays and receiving faxes for claims or medical records not in the system. A majority of the calls came from world’s clients relating to rescinded policies, claims, and contract validation. This position required great skill in communication with other departments and as well with world’s clients. This entitled me to use email, fax, and pulling files for contract validation, outbound calls and a great deal of empathy. Utell International Omaha, NE 1999-2001

Reservation Sales Rep

Customer Service Liaison

This position started for me on the reservation sales floor of their international hotels line group. I made direct bookings for hotels around the world via inbound calls. As with any sales position I had quotas to meet, attendance, conversion, and monitoring. I would meet all my stats and receive a monthly bonus.

Customer Service Liaison

After 7 months on the sales floor my supervisor recommended me to the reservation manager that I would be a good fit with the new projects that is in the works for one of their luxury brand hotels. I was promoted to customer service liaison for Summit Hotels five star brand. My duties included fielding customer service calls and follow up service calls per outbound calls. This was done to resolve any issues between the hotels and their guests. To resolve issues, direct correspondence was done by phone, fax, email to the hotels general manager. My position also entitled me to do group bookings, waive no shows, and issue refunds under careful investigation. I also handled any customer service issues for travel agents booking system (global distribution systems) by relaying back any bookings violations.

Education

Metropolitan Community College

Computer Programming – 2000-2001

Majoring in Business Administration – 2002

Pine Ridge Job Core – Chadron, NE Graduated in 1989 308-***-****)

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