Call Center Claims Specialist
Resume:
Diana L. Gray
*** ******* ***** **. *** ****, Villa Rica, GA 30180
770-***-**** ********@*****.***
“Proactive Team Player and Reliable”
Professional Experience:
Verida – Claims Auditor April 18, 2023 to current
Conduct audits and reviews of claims. Document the findings and recommendations.
Request all information from internal or outside sources to ascertain completeness and validity of claims.
Analyze claim trends to determine any necessary refinement of business rules and workflows in order to improve the overall claims process.
Contribute to the development of claims analysis reports.
Research claims as needed.
Verida – Claims Specialist I October 17, 2022- to April 18, 2023
• Correlate the reimbursement request forms and resubmissions by provider per day in chronological order.
• Approval and denial claims for reimbursement and resubmissions.
• Responsible for generating and distributing copies of denied reimbursement request to providers.
• Filing all reimbursement forms.
• Assisting with special rates from the Call Center.
• Relays instructions, messages and other information as requested from the management team.
• Maintains a current working knowledge of all company policies, procedures, rules, regulations and memorandums.
• Responsible and accountable for updating management on changes and/or extraordinary circumstances affecting the company and/or transportation provider.
• Other duties as assigned by management team
Modivcare - Service Expert Specialist II - 2021-2022
●Records and initiates investigation of complaints, grievances and general issues via phone and all incoming communication channels
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●Initiates corrective actions
●Work closely with other work streams to complete investigation
●Collects all necessary supporting information to accurately provide a resolution
●Monitors the complaint aging report in order to comply with turnaround requirements on resolution
Modivcare Transportation Customer Advocate 2012-2015 and 2020-2021
●Schedule route and dispatch trips to all manner of providers
●Assist in coordinCommunicate with transportation providers when applicable
●Identify and resolve problems with transportation provider billing invoice forms
●Meet all departmental deadlines
●Work closely with the Fraud and Abuse departmentation of mass transportation when needed
●Administer trips for volunteer/ independent drivers and mileage reimbursement program
●Completes all documentation and process task associated to mileage mapping and application procedures if responsible for volunteer/ independent drivers and mileage reimbursement programs
●Works closely with transportation providers and health care facilities to resolve problems
●Assigns reservations to network providers to ensure that vehicle resources are used most efficiently and effectively to meet client demand
●Responsible for daily communication with transportation providers
●Ensures accurate trip data input
●Other duties as assigned.
Modivcare - Claims Processor 2015-2020
●Communicate with transportation providers when applicable
●Identify and resolve problems with transportation provider billing invoice forms
●Meet all departmental deadlines
●Work closely with the Fraud and Abuse department
Modivcare - Customer Service Representative - Jan 2012
●Receives and documents customer concerns while ensuring all relevant information is correct
●Adheres to and ensures all company policies and procedures
●Maintains an acceptable attendance and tardiness record
●Ensures accurate trip data input
●Demonstrates personal commitment to producing high quality work
●Refers unresolved customer grievances to designated department for further investigation and resolution
Education: Diploma – Northmont Senior High School
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