Customer Service A Medical

Paige Johnstone

The Villages, Florida *****

Education

Stuart School of Business, Lincroft, NJ

Business/Health, Certification Diploma

Brookdale Community College, Lincroft, NJ

Business Management

Certifications

Chamber of Commerce

NJ Rotary

Notary of Public Certification

Skills

Strong Customer Service Skills

Exceptional Claims processor

Strong Leadership skills

Professional Experience

Caremetx Benefits Administration Specialist

Sept 2024-February 2024

Benefits Verification is a remote position responsible for performing specific reimbursement functions associated with completing a medical and/or pharmacy benefit investigation. Will utilize data from the benefit verification transaction to complete a medical benefit investigation. This process involves calling on specific payers to obtain the necessary missing data to finalize the benefit investigation. Once the data is obtained from the payer, the Reimbursement Specialist will enter the data into system using pre-established protocols. The Reimbursement Specialist may also complete other documentation as required for daily reporting and performance measurement activities.

Vail Claims Administrator/Workers Compensation Claims Specialist/ Help Desk Technician

May 2022 – Sept 2023

Effectively managed a portfolio of various types of claims.

Updated and maintained claim files to ensure complete records.

Responded timely to internal and external inquiries for information relative to claims.

Reviewed, prepared, created, and/or sent letters, reports, forms, appeals, etc.

Communicated claim action/processing with the claimant, client, and appropriate contact.

Identified notification issues, coordinated resolution, and took corrective actions as needed.

Engaged and addressed any customer inquiries related to lien/bond claim notices sent to property owners, general contractors, and subcontractors.

Collaborated with the claim handlers in preparing the claim notices.

Maintained action plans to meet state-required contract deadlines and move the file toward prompt and appropriate resolution. escalates issues as needed.

Provided support and assistance in updating reinsurance systems and information.

Facilitated prompt communication with all parties to expedite claims processing, including referral to and coordination with specialty units.

Assisted staff with multiple claims issues.

Provide assistance to employees to fill out claims

-Review claims filed by employees for completion and timely submission related to incident

-Oversee that medical documentation submissions falls within acceptable time frames

-Track claims from filing through follow-up with employee supervisors

-Notify safety manager or compliance officers of employee incident and claim

Identifying hardware and software solutions.

Troubleshooting technical issues and resolving network issues

Manage incident case file and ensure employee access to information

Provide information concerning compensation claims for medical or rehabilitation costs

Document contacts with employee while away from the workplace on medical or disability leave

Coordinate with payroll personnel concerning continuation of pay or light duty hours

Contact medical providers to confirm employee’s work status

Monitor compensation plans and strategies for cost effectiveness and regulatory compliance

Suggest program improvements for compensation benefits plans

Work on both hardware and software issues and upgrades.

Have experience on both Desktop and Laptops.

Troubleshooting the printers and scanners

Handling Inbound and Outbound calls to resolve customer queries.

MCS Customer Service Operator

January 2019 – April 2022

Record Retrieval Company for Attorneys.

Calls to over 150 providers daily for needed medical records.

Monitored for Production and Quality.

Handled both inbound and outbound calls.

Handled various calls related to customers’ complaints and queries.

Prior Authorization

Used MS Excel for purposes of spreadsheets, and data entry.

Maintained filing system and records by receiving, sorting and distributing incoming and outgoing Data.

Stresscare of NJ, Matawan NJ Supervisor Medical Billing Department

December 2017 – November 2018

Accomplished billing human resource objectives by selecting, orienting, training, assigning, scheduling, coaching, counseling, and disciplining employees; communicating job expectations; planning, monitoring, and appraising job contributions; recommending compensation actions; adhering to policies and procedures.

Met billing operational standards by contributing billing information to strategic plans and reviews; implemented production, productivity, quality, and customer-service standards; resolving problems; identified billing system improvements.

Met billing financial standards by providing annual billing budget information; monitored expenditures; identified variances; implemented corrective actions.

Accomplished billing departmental objectives by measuring billing results against plans; evaluated and improved methods; made required changes.

Use to attend 100 calls a day

Guided employee actions by researching, developing, writing, and updating billing policies, procedures, methods, and guidelines.

Obtained revenue by resolving order and invoice disputes; maintained customer relations; resolved problems with the bank transfers.

Attended various calls which includes inbound and outbound both

Prior Authorization Supervisor

Med-Metrix, Neptune, NJ Medical Biller-A/R Representative/ Customer service rep

January 2017 – December 2017

Worked with the Hospitals to secure payment of accounts from the Insurance Companies.

Appeals, Collections, and Follow-Up.

Promptly responded to general inquiries from members, staff, and clients via mail, e-mail, and fax.

Reviewed collection files to determine the next steps in the collection process.

Reviewed data to verify the validity of claims, follow-up on accounts researched, and resolved billing and invoice problems.

Dealt with customers' problems.

Prior Authorization.

Horizon Blue Cross Blue Shield, Wall Township, NJ Call Center Representative/Coach/Supervisor/Quality Auditor

August 2006 – December 2016

Quality Auditor for National Accounts, a call center serving 50 States, resolving customer issues, processing claims, and processing heavy call volume.

Helped team members, customers, and providers with any issues that were needed with claims, edits, and calls.

Addressed negative customer feedback immediately.

Monitored and audited and effectively communicated with team members to maintain clearly defined expectations.

Resolved customer questions, issues, and complaints.

Responded to all customer inquiries in a timely manner.

Emphasized product features based on analysis of customers' issues.

Worked as a Managed Care Coordinator, Prior- Authorization dept. for our providers, heavy call volume, and imputing authorizations in our system.

Worked as a Managed Care Coordinator, Prior- Authorization dept. for our providers, heavy call volume, and imputing authorizations in our system.

Provided accurate and appropriate information in response to customer inquiries.

Demonstrated mastery of customer service call script within specified time frames.

Addressed customer service inquiries in a timely and accurate manner.

Developed effective relationships with all call center departments through clear communication.

Worked on various programs for Horizon such as NASCO, Qblue, New membership, UCSW, and OLI.

Maintained Production and Quality in all areas.

Prior authorization Team Lead, Pre-Determination

Claims processor.

Pends/Claims.

Helped customers if they have some complaints.

Shopping Spree Matawan, NJ Sales Territorial Manager

July 2005 – August 2006

Advertising Sales Manager, responsible for securing business accounts and advertising for business profits Led sales calls with team members to establish sales and customer retention goals.

Monitored customer preferences to determine the focus of sales efforts.

Generated monthly and annual sales reports.

Created and directed sales team training and development programs.

Shared product knowledge with customers while making personal recommendations.

Maintained friendly and professional customer interactions.

Cold-called prospective customers to build a relationship.

Completed documentation for product and service sales.

Generated a high volume of referrals.

Established new customer accounts.

Delivered exceptional account service to strengthen customer loyalty.

Established 40 new accounts in only six months through successful client development.

Somerset Valley Bank, Aberdeen, NJ Branch Manager/ Assistant Treasurer

January 2003 – July 2005

Educated customers on the variety of loan products and available credit options.

Exceeded quarterly sales goals by 80%.

Adhered to all federal and state compliance guidelines for retail mortgage lending.

Implemented annual performance. Appraisals for all branch staff.

Developed the annual branch business plan for maximum profitability and effectiveness.

Recruited and hired new branch employees.

Mentored staff to increase sales success and productivity.

Developed standard operating procedures.

Planned and executed promotional events.

Monitored key performance metrics.

Modelled trends and adjusted branch plans accordingly.

Consistently complied with company policies and government regulations.

Completed financial analysis of revenue.

Coordinated special update and conversion projects.

Designed sales and service strategies to improve revenue and retention.

Affiliations

Training seminars for supervisor skills

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