Customer Service Support Specialist
Resume:
Gina Moreno
San Antonio, TX ***** 210-***-**** *************@*****.***
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WORK HISTORY CLAIMS SUPPORT SPECIALIST
Healthsmart Benefit Solutions San Antonio, Tx
Worked productively in fast-moving work environment to process large volumes of claims.
Analyzed and addressed escalated claims to resolve issues quickly. Collaborated with internal departments and external vendors to achieve fast resolution of claims.
Followed up with customer service department on unresolved issues. Researched and analyzed complex claims to determine next steps and possible outcomes.
Maintained accurate and up-to-date records of claim information for future reference.
Examined reports, accounts, and evidence to determine integrity and accuracy of information.
Prepared and presented detailed reports to management on claims issues to aid in decision making.
Developed and implemented strategies to improve claim processes. Generated, posted and attached information to claim files. Provide monthly audit results to manager in regards to completed examiner processed claims and incoming customer service transmittal calls.
CLAIMS EXAMINER
Healthsmart Benefit Solutions San Antonio, Tx
08/1999 to CURRENT
Paid or denied medical claims based upon established claims processing criteria.
Maintained knowledge of benefits claim processing, claims principles, medical terminology, and procedures and HIPAA regulations. Verified patient insurance coverage and benefits for medical and dental claims.
Managed large volume of medical claims and dental claims on daily basis. Monitored and updated claims status in claims processing system. Reviewed provider coding information to report services and verify correctness.
Evaluated medical claims for accuracy and completeness and researched missing data.
Identified and resolved discrepancies between patient information and claims data.
GM
Responded to correspondence from insurance companies. Followed up on denied claims to verify timely patient payment and resolution.
Researched and resolved complex medical claims and dental claim issues to support timely processing.
PROFESSIONAL
SUMMARY
Qualified Claims Examiner and Claims Support Specialist versed in investigating claims, verifying information and highly experienced in claims processing and claim auditing. Friendly and upbeat team player with organized and disciplined approach. Offering 24 years of insurance experience. ACCOMPLISHMENTS I have built a good rapport with our external PPO networks. I work closely and professionally with them when consulting on issues, rush repricing or delay in returns. I work together with them on ways to improve the delay repricing and how we could help one another. This process has helped their turn around time from 30 days to 14 days.
SKILLS Medical Terms and Procedure
Knowledge
Policy Requirements and
Eligibility
Learning Strategies
ICD Codes
HCPCS Codes
CPT Codes
UB92 Bills
HCFA Bills
Dental Bills
Medical Terminology
Benefits Guidelines
Insurance Coverage Limits
Critical Thinking
Knowledge of HIPAA Regulations
Customer Service
Health Insurance Industry
Knowledge
Policy and Procedure
Explanations
Microsoft Office
Report and Records Review
Customer Inquiries
Time Management
Project Requirements
Great Mathematical Skills
Creative Solutions
Production Goals
Special Projects
Claims Adjustments
Active Listening
Team Meetings
Information Updates
Special Handling
Complex Problem-Solving
Rim System
Quicklink System
Document Uploading
10-Key Touch
EDUCATION BACHELOR OF BUSINESS MANAGEMENT EXPECTED IN 12/2024 BACHELOR OF BUSINESS MANAGEMENT
UNIVERSITY OF PHOENIX, Phoenix, AZ
High School Diploma
Mccollum High School, San Antonio, TX
05/1991
CERTIFICATIONS Dean Vaughn medical terminology 1,2,3, Anthem - 1996
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