Claims Professional
Resume:
Naimah Fields
Albrightsville, PA 18210
************@*****.***
Objective: To obtain a full time position that will allow me to utilize my current skills, while developing and implementing new strategies and skills with growth possibilities. Seeking to build new business relationships and maintain current relationships.
Work Experience
Team Leader
Horizon Casualty Services - Newark, NJ
2008 to Present
Review and adjudicate complex medical bills in accordance with
established policies and procedures.
Responsible for the daily management of staff and inventory to ensure delivery of exceptional customer service.
Evaluate strengths and weaknesses of staff in order to foster a positive working environment which includes:
Daily evaluations, coaching and mentoring the business team in order to enhance staff performance levels for quality, production, and attendance while ensuring accuracy and compliance with internal/external policies.
Allocate work assignments to ensure daily receipts are processed in accordance with Service Level Agreements (SLAs) based on order of receipt. Review work load to identify gaps in processes and/or inefficiencies. Incorporate applicable workflows and business rules. Perform appropriate data analysis and reporting.
Ensure customer satisfaction by developing business partnerships with internal and external customers for seamless results and by expediting resolutions of complex problems/issues either by resolution, or escalation.
Monitor and track expenses as tied to the defined budget.
Provide coaching/mentoring to less experienced staff members and peers.
May oversee multiple work teams and/or servicing of multiple projects.
May participate in and/or lead departmental and interdepartmental workgroups.
Perform other relevant tasks as assigned by management.
Perform analysis for Hospital, Ancillary, Ambulatory Surgery Centers, and Physician’s contracts, to ensure bill processing accuracy. Perform re-pricing exercises in a UAT Environment to assist with Process Improvements. SOC2 Recertification, Quality and Audit Reportings.
Implementation of the PIP Fee Schedule and Service Level Agreements. Determine the level of care for
Inpatient bills by reviewing Rev Codes, HCPCS Codes ICD-9 Codes, and DRG’s.
Provider Senior Associate
Cigna HealthCare - Jersey City, NJ
2003 to 2007
Coordinated the front end of the physician credentialing process.
Facilitated the collection and review of pertinent information. Respond to complex correspondence.
Provided customer service for providers, education, claim resolution, and contractual obligations.
Developed and maintained positive relationships with physicians and practice managers within the network. Educate plan's policies and procedures. Resolved provider's complaints and disputes by examining and processing claims.
Provider Relations Representative
Operating Engineers Local - Springfield, NJ
2000 to 2003
Recruitment, contracting, and retained qualified providers within the geographic area.
Conducted all aspects of physician education and services. Educated providers on health plan policies and procedures and participation requirements. Provided administrative support including typing
correspondence, reports, and completion of benefit summaries.
Processing of facilities and physician medical claims. Implementation of fee schedule.
Administrative Assistant
University Family Medicine - Baltimore, MD
1996 to 2000
Provided high level administrative tasks including supervising one or more employee.
Planning events, meetings, and conferences. Handled incoming calls from patients or physicians.
Collected members copay when needed and insurance verification and referrals. Proofread and typed correspondence.
Education
2012-2015 Ashford University
Business Management
04/01/2011-10/16/2011 Horizon Blue Cross Blue Shield
Completion of the Supervisory Candidate Program
05/2022-08/17/2022 Horizon Blue Cross Blue Shield
Completion of Pathways to Leadership Program
1990-1995
Fredrick Douglas Senior High School High School Diploma Baltimore, MD
High School Diploma
Additional Information
Skills: Ms Word, Excel, 50 WPM, Ms Outlook, Internet, Lotus, Access, Medical Terminology, Coaching, Cognos, Training, Contracting, Claim Processing, Data Entry, Medical Billing and Coding, Time Management, Reliable, Dependable, Communicates well with others, Computer literate, Multitask, Customer Service.
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