Accounts Receivable Claims Analyst
Resume:
ROSEMARY S. KAUFFMAN, ACS, ALMI
****************@*****.***
www.linkedin.com/pub/rosemary-kauffman/34/186/8b0/
Princeton MO 64673 (C) 267-***-****
SUMMARY
Experienced Accounts Receivable Representative and Claims Analyst with over 25 years’ experience in the medical and insurance fields.
Expertise Includes:
HIPAA trained
Effective planning
Organizing
Problem solving
Multi-Tasking
Managing heavy volume and functioning well under pressure
Possess very strong interpersonal and leadership skills
PROFESSIONAL EXPERIENCE
Health Partners Plans
2020-Present
Member Relations Philadelphia, PA
Primary Responsibilities:
Educate callers about Health Partners’ plan with the intent of retaining members.
Provide high levels of service.
Report on trends and issues which impact the membership.
Collaborate with internal departments to facilitate resolutions to member’s issues and concerns.
Respond to member and member-related calls in a courteous, professional& efficient manner providing timely follow-up to requests for information and service.
Participate in and conduct new member orientation outreach on a monthly basis as assigned.
Answer eligibility, benefits and provider inquiries, assuring that members receive service, use the plan correctly and gain a high level of satisfaction with the plan.
Maintain call records, logs and other documentation in accordance with departmental requirements.
Operate MIS and telephone systems effectively and efficiently, following established protocols for security, transfer and information exchange.
Participate in appropriate staff meetings and training sessions, reporting on trends and issues which impact members and Health Partners as a whole.
Attend monthly meetings.
Perform other clerical and support tasks as assigned.
Reliance Standard Philadelphia, PA
2018- 2020
LTD Claims Examiner
Prompt and thorough investigation of claims within departmental and regulatory guidelines.
Interprets and administers contract provisions including, but not limited to, eligibility, covered monthly earnings, definition of Total Disability, verification of applicable offsets and pre-existing investigations.
Develops implements and modifies disability management plan to establish strategy and manage outcome.
Documents claim file actions and telephone conversations appropriately.
Refers claim activity outside authority level to Supervisor/Manager for review.
Pro-actively communicates with claimants, policyholders, physicians to resolve investigations issues.
Establishes, communicates and manages claimant and policyholder expectations.
Utilizes most efficient means to obtain claim information.
Fully investigates all relevant claim issues, provides payment or denials promptly and in full compliance with departmental procedures and Unfair Claims Practice regulations.
Responds to customer service issues within required timeframes.
Involves technical resources (Social Security Specialist, medical resources, and vocational resources) at appropriate claim junctures.
Refers claims above ability to a supervisor/manager.
Demonstrates ability to independently investigate, evaluate and adjudicate claims of moderate degree of complexity.
Supports relationships with technical resources to achieve appropriate outcomes.
Actively contributes to departmental service, quality and production objectives.
Remains current with all corporate and disability management practices.
Collaborates with team members and management in identifying and implementing improvement opportunities.
May mentor less experienced examiners.
Assists in review and assessment of claim settlement opportunities.
Collaborates with management on claims with high degree of complexity.
All other duties as assigned.
Reliance Standard Philadelphia, PA
2017-2018
Customer Care Center
Handles customer complaints and inquiries in a timely and courteous manner.
•Provides information on in-force products to Agents, Policyholders and Employees.
Communicates contract language in terms callers will understand.
Resolves with customers a wide variety of problems.
Provides clear and concise information on problems that require research beyond that
which can be handled by a Representative.
Maintains a log of incoming calls from customers and field personnel.
Follows through to ensure that problems and requests are handled satisfactorily.
Follows up on telephone inquiries.
Communicates with Policyholders and Agents on policy changes.
Completes specific projects relating to policies.
Assists other departments in handling customer service problems.
Understand the process for address and correspondent changes
Ability to discuss electronic billing and provide information on how to download a
free upgrade or enroll online.
Provide assistance with questions on Smart Choice, VIP and other products as they
become available.
All other duties as assigned
Aria-Jefferson Health Physicians Services Philadelphia, PA
2015-2017
Collections/Billing
Placed follow-up calls to insurance companies for claims with open dates of service
Resolved disputes and denials that may have been received as a “reply” rather than payment
Documented and updated all notes pertaining to patient cases into the computer system
Sorted through daily mail and correspondence submitted by the insurance companies
Gathered necessary information needed by the Medical Billers to post medical payments
Posted payments and made adjustments to patient ledgers
Resubmitted claims. Identified and trended consistent problems with various payers
Coordinated special projects as assigned
Med Protect LLC
2012-2015
Global TRICARE Service Center (GTSC) Beneficiary Service Representative
Process enrollment/disenrollment and portability using the Defense Online Enrollment System (DOES).
Assigns primary care managers (PCM) to TRICARE Beneficiary as appropriate.
Verifies eligibility information for remote beneficiaries.
Researches and interprets benefits, policies and procedures to military staff, remote site Points of Contact (POCs), and beneficiaries using TRICARE Policy Manuals as well as other resources
Provide customer support to the Military Treatment Facility (MTF) Commander and or the TRICARE Area Office staff as directed by the Regional Lead, Deputy Program Manager or Program Manager.
Providing education and enrollment information to beneficiaries
Other various duties as assigned.
Apollo Health Street Conshohocken, PA 2010 - 2011
Collections/Billing
Performed Follow-up with insurance companies for outstanding hospital claims and obtain payments in a timely manner
Contacted patients for insurance information or pending information
Resubmitted claims. Identified and trended consistent problems with various payers
Coordinated special projects as assigned
Dr. William J O’Brien III Bristol, PA 2009 - 2010
Collections/Billing
Placed follow-up calls to insurance companies for claims with open dates of service for Workman’s Compensation, Slip and fall and Motor Vehicle
Resolved disputes and denials that may have been received as a “reply” rather than payment
Worked with PI Coordinators and Front Desk personnel to resolve disputes
Documented and updated all notes pertaining to patient cases into the computer system
Sorted through daily mail and correspondence submitted by the insurance companies
Followed-up on patient cases by contacting the assigned attorney, as well as the PI Coordinator
Gathered necessary information needed by the Medical Billers to post medical and/or injury payments
Scanned documentation into the computer system to assure the information is readily available to those who may need it to assist the attorney
Posted payments and adjusted patient ledgers
Alliance One Receivables Trevose, PA 2007 - 2008
Collections/Billing
Contacted customers regarding past due credit card amounts owed before charge-off
Helped and educate customers with payment options and work closely with client for various assistance programs
Skip traced accounts to find customers
Various other duties as assigned
Arc Group Associates, Jenkintown, PA 2006 - 2007
Collections/Billing
Performed Follow-up with insurance companies for outstanding hospital claims and obtain payments in a timely manner
Contacted patients for insurance information or pending information
Resubmitted claims. Identified and trended consistent problems with various payers
Coordinated special projects as assigned
Home Care Supply/Praxair, Huntington Valley, PA 2004 - 2006
Collections/Billing
Worked with assigned insurance companies on a daily basis to receive information necessary to bill and collect for durable medical equipment rentals and sales
Managed Keystone 65 and Keystone Health Plan East - revamped and collected the back billing for these insurance plans
Managed Personal Choice, Personal Choice 65, AmeriHealth Personal Choice and AmeriHealth Administrators
Reviewed edit list to ensure that billing is accurately submitted to the corresponding insurance company
Managed cash input and output for the Company; billing and collections
Handled general customer service questions to existing and prospective patients
Coordinated the A/R report
Double H Plastics, Inc., Warminster, PA 2003 - 2004
Customer Service Representative
Maintained relationships between outside vendors and external client account managers
Processed client requests for both versa form lids and plastic core products
Compiled and distributed inventory analysis reports for customers
Created procedure manual for the Customer Service Department
Directed phone calls to appropriate personnel within the company
Managed billing for both versa form lids and plastic cores
Aon Select/CBCA, Horsham, PA 1996 - 2003
Claims Analyst
Processed Medicare Supplement Claims, PPO Claims and various other health claims
Maintained an average of 135 claims daily or 675 claims per week
Provided superior customer service to patients and providers
Managed general office duties such as: filed and copied documents as needed
Coordinated special projects as assigned
EDUCATION
Bucks County Technical School, Nursing (1984)
Bensalem Senior High School
High School Diploma: Received Perfect Attendance Award for all 4 years of school
COMPUTER SKILLS
AS/400, Word, Excel, Windows, Lotus Notes, Dezine, Mestamed, Doctor.com, E-Premise, Emedeon, Medicare system, Navi net, CPSI, Deer’s/Does, etc.
Obtained ADP2/IT2 Clearance as of 5-2012
Obtained ACS ALMI and FLMI 1 2017
Contact this candidate