Human Resources Customer Service
Resume:
MICHAEL CLARKE
Tamarac FL
33321
Job Title
Start Date (MM/YYYY)
End Date (MM/YYYY)
Convey Health - Remote
Licensed Agent
May 2020
Jan 2023
Aetna, Managed Staffing - Plantation FL
Credentialing Coordinator
Aug 2019
Apr 2020
W2,Pay stub
Teleperformance - Fort Lauderdale, FL
Provider Enroller
Aug 2018
Jan 2019
W2, Pay stub
Education Completed
Bachelor of Arts in Theology, Jamaica Theological Seminary, Kingston, Jamaica 2004
Copy Available
Michael Clarke
Skills:
Medicare & Medicaid Reimbursements
Customer service
Provider Data
Credentialing
Contract Negotiation
Provider Enrollment
Medicaid
Medicare
Databases
Human Resources
Medical Terminology
Event Planning
Public Speaking
Data collection
Training & development
SharePoint
Administrative Experience
Microsoft Excel
Research
Credentialing
Re-credentialing
Teambuilding
Decision-Making
Excellent Communication
Analytical and Critical Thinking
Written Communication
Self-Motivated
MS Office
Problem-Solving
Organization and Time Management
Education:
Bachelor of Arts in Theology, Jamaica Theological Seminary, Kingston, Jamaica 2004
Licence: W000772
NPN :15834656
Professional Experience:
Convey Health - Remote May 2020 - Jan 2023
Licensed Agent
Management of enrollments, changes, and terminations.
Determines the acceptability of provider enrollment applications (which may be used for initial full application)
Initiate and coordinate the acquisition and receipt of enrollment/credentialing documentation from new and existing providers; provide follow-up and problem resolution as required
Coordinates the processing, distribution, and management of all credentialing and accreditation documents for affected providers.
Maintain accuracy and completeness of the internal credentialing database.
Review payer plan applications returned to the department for accuracy and completeness, troubleshooting as needed.
Sell individual health plan products and services in a field setting.
Make sales presentations to eligible qualified Medicare persons - virtually.
Initiate sales opportunities with seniors, individually or in groups, to sell individual health plan policies.
Make virtual presentations to prospective seniors or senior groups to increase enrollment. Influence department’s strategy.
As an Advocate Health Advisors Sales Representative sells individual health plan products and services in a field setting tailored to each individual’s needs.
Under minimum supervision, initiates sales opportunities with seniors, individually or in groups, to sell individual health plan policies.
Plan, implement and maintain delegated credentialing processes/status with insurance companies
Assisting in initiatives and performing special projects and other duties as assigned by leadership
Assists members and agency personnel in person and by telephone completing and filing claims for service, disability, and survivor benefits.
Maintains regular contact with persons in other departments or other agencies to coordinate claims processing requirements, resolve problems, furnish or obtain information, and explain retirement benefit rules and regulations.
Sourcing, comparing, and presenting various drug formularies with attendant prices presented in the form of notes for permanent record, and follow-up.
Make concise and detailed notation as it pertains to member account.
Advise providers on how to get prior authorization on medicines prescribed with restrictions such as step therapy and quantity limits.
Aetna, Managed Staffing - Plantation FL Aug 2019 - Apr 2020
Credentialing Coordinator
Management of benefit enrollments, changes and terminations.
Identified, researched, and resolved billing variances such as charge review, claim edits, and denials within EPIC (EHR system) as related to Medicaid and Medicare enrollment for the Physician Organization Business Office
Plan, implement and maintain delegated credentialing processes/status with insurance companies
Assisting in initiatives and performing special projects and other duties as assigned by leadership
Educating providers on the performance requirements associated with value-based contracts.
Establishing and managing strong, solid relationships with assigned provider groups and their staff (i.e. physicians, practice managers, care coordination teams), as well as executing with provider groups on initiatives that benefit the customer, provider, and health plan.
Assist with for inputting credentialing information into the departmental credentialing system, as necessary to support the Credentialing process
Actively process forms, request payer applications, maintain file system, follow up on issues and troubleshoot problems. Maintain and ensure strict confidentiality of files and database
Determines the acceptability of provider enrollment applications (which may be used for initial full application)
Receiving and making calls to provider offices
Approving and authorizing medications, that are recommended by the provider
Informing customers on a timely basis of denial or approval of medicines
Making recommendations of generic drug
Maintaining HIPPA regulations
Updating CMS changes to records
Attendance of regular training
Attending weekly EBEX meetings
Meeting daily targets and goal
Gap Reason - Took a gap due to personal reasons Feb 2019 to Aug 2019
Teleperformance - Fort Lauderdale, FL Aug 2018 - Jan 2019
Provider Enroller
Provides information in person and by telephone regarding specific statutory provisions, rules, and regulations governing benefits available to members
Assists members and agency personnel in person and by telephone completing and filing claims for service, disability, and survivor benefits.
Researches, compiles, analyzes, and interprets important detailed, often complex employment and wage and contribution records for determination of service credit eligibility and calculation of benefit amounts.
Maintains regular contact with persons in other departments or other agencies to coordinate claims processing requirements, resolve problems, furnish or obtain information, and explain retirement benefit rules and regulations.
Enrolling individuals into Medicare Advantage plans
Enrolling individuals into Medicare plans, including parts A, B, C and D
Enrolling individuals into Dental and Vision plans
Follow up calls to individuals who have made inquiries about enrolling into various plans
Educate members and prospective members about various type of plans that are available
Make sales to individuals
Provide optimal service to all contracted providers, including hospitals, physicians and ancillary groups.
Assists with claims, appeals, billing and eligibility.
Knowledge of National Uniform Claim Committee, verse in HIPAA laws, and HIPAA compliant
Knowledge of various plans etc., HMO, HMO/ POS, HMO -SPN AND PPO
Knowledge of the various types of claims, and benefits
Strong analytical, problem-solving, and conflict resolution skills
Excellent oral and written communication skills
Must be able to read, review and analyze reimbursement contracts from managed care insurance
Basic knowledge of CPT & HCPCS coding language ICD-9 & ICD-10
Knowledge and understanding of UB04,1500 and EOBs/RAs
Contact this candidate