LaTodra Pearlene Burnley

Mesquite, TX - *****

Broadband connection and Ethernet connection required - AT&T Internet

Download speed: 242.94 MBPS and Upload speed:50.05 MBPS

Professional Summary:

Experienced in clinical setting with Prior Authorization, Medicare and Medicaid.

Excellent customer Service and communication skills.

Learn new tasks quickly for incorporation into the job.

Skilled with Data Entry and Medical Terminology.

Knowledgeable with HIPAA guidelines, CPT and ICD-10.

Education:

South Oak Cliff High School - Dallas, TX

August 1998 to May 2002

High school diploma.

Skills:

Data entry (45 WPM)

Customer Service

Prior Authorization

Inbound & Outbound Calls

Medicare/ Medicaid

Communication skills

Medical Terminology

Interpersonal skills

Organizational Skills

Microsoft Office (Outlook, Word & Excel)

HIPAA guidelines, CPT and ICD-10.

Professional Experience:

Humana-Remote

April 2022-July 2023

Medicare/Medicaid Claims Research & Resolution Specialist

Responsible for performing benefits verification and prior authorization Functions to ensure optimal reimbursement for high cost medications, surgeries and procedures, within an established time frame, for patient cases submitted to Patient Financial Services.

Ensures correct referral form is completed for patients plan. Reviews referral for accurate information prior to authorization to include patient provider Identification information, clinic or procedure requested, and appropriate CPT-4 /billing codes. Contacts clinic to obtain additional information as needed.

Serve as a resource or Subject Matter Expert for other team members or Internal customers.

Review scheduled procedures to determine rather prior-authorization and process Medicaid and Medicare Part D with CMS Regulations.

Handle escalated calls, resolving more complex customer issues in a one and done Manner.

Answer incoming phone calls from customers and identify the type of assistance the customer needs (i.e. benefit and eligibility, billing and payments, authorizations for treatment and Explanation of benefits (EOBs.

Ask appropriate questions and listen actively to identify specific questions or issues while documenting required information in computer systems

Intervene with care providers (doctor’s offices) on behalf of the customer to Assist with appointment scheduling.

Robert Half - Remote

June 2021 to March 2022

Claims Data Entry Specialist

This is entry-level professional interviewing and related work in the unemployment insurance benefit/ claims program of the Missouri Division of Employment Security.

Secures and evaluates information required to process state and federal unemployment insurance claims; shared work claims; and claims for training, subsistence, and transportation allowances under various employability programs.

Entered data regarding unemployment insurance benefits into the system.

Entered data regarding claims.

Used knowledge regarding HIPAA guidelines, CPT and ICD-10.

Secures detailed information from claimants and enters data into the computer system; determines the type of unemployment claim to be filed under state and federal unemployment insurance programs.

Secures, documents, and investigates detailed and sensitive information from claimants involved in disputed claims, including such complicated issues as separation from work, availability for work, refusal of work, participation in a labor dispute, and overpayment investigations.

Secures and documents additional technical information from employers and other interested parties by telephone interviews and correspondence to obtain complete facts.

Obtains facts and issues determinations relevant to a trainee’s eligibility status for federal allowance payments under employability programs.

Evaluates information, applies proper section of the law to the facts, and prepares non-monetary determinations for forwarding to interested parties.

Reviews and evaluates new information received after a determination has been issued and decides if an appeal or different determination is necessary.

Interviews claimants and secures information concerning previous wages earned and weeks worked; determines if additional wage credits should be applied or if there is an overpayment of benefits.

Corresponds and communicates with claimants, employers, Central Office, and state and federal agencies to correct errors, resolve problems, and facilitate claims processing.

Attends training sessions and meetings to remain aware of program procedures and law changes. Studies new and revised agency procedures, rules, laws, regulations, and other program changes contained in manuals to maintain currency of knowledge and information.

Applies established procedures for control of overpayment and fraud on all types of claims.

Receives assignments in cases of potential overpayment of erroneous or fraudulent claims; collects and evaluates information; and establishes facts and makes recommendations and determinations consistent with law.

Interviews claimants with outstanding overpayments and arranges for restitution.

Communicates with financial institutions to resolve complex cases involving lost/stolen/forged checks, direct deposits, or debit card payments on unemployment claims.

Exercises independent judgment and initiative within established policies and procedures; receives general supervision and performs other related work as assigned.

Robert Half (Remote)

March 2020 to May 2021

Mortgage Processor specialists - Entry Level

Review and process Mortgage accounts

Follow State Guidelines per Mortgage requirements.

Set payment take payment arrange correct setting to modify needs per customers mortgage. Refer to set departments for special needs.

Fulfill all required needs of customers to keep mortgage in good standings.

Regional Acceptance Corporation - Remote

January 2016 to November 2017

Payment Processor

Assisted customer queries over the phone, email and face to face and Conducted payments via electronically.

Locate and monitor overdue accounts through the computer and automated system.

Traced delinquent customers to new addresses by inquiring at the post office, telephone companies and credit bureaus.

Document payment arrangements, special arrangements and repayment plans.

Capital One - Remote

January 2016 to November 2017

Payment Processor

Prevent impending losses and increase profitability through negotiated

Initiated consumer negotiations for debt recovery

Negotiated settlements or monthly payment allowances within guidelines Set up payment plans to settle overdue balances

Santander consumer USA - Remote

March 2014 to December 2015

Funder

Make customers feel welcomed and accepted when taking phone orders Patient with demanding customers over the phone and in person

Maintain account information Record detailed inquires, complaints and concerns

Relay information in a concise and clear manner about products and procedures

Quickly understand and interpret customers’ needs and wants

Research and investigate issues that concern customers

Collect past due invoices and payment arrangements

Resolved account issues and noted the account of resolutions.

HMS - Remote

March 2014 to December 2015

Customer Service Representative

Record necessary information to investigate actions as required.

Record detailed inquiries, complaints and concerns.

Used knowledge regarding HIPAA guidelines, CPT and ICD-10.

Process orders, forms, applications and request for information.

Keep up to date information on company products, services and procedures.

Quickly investigate issues and noted the account of resolutions.

Made payment arrangements and collect past due invoices.

Reviewed policy terms and ensure loss was covered.

Contact this candidate