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Medical Insurance

Location:
Troy, MI, 48084
Posted:
March 25, 2021

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Resume:

Carla Harrington

Detroit, MI ***** adk6ua@r.postjobfree.com

313-***-****

Work Experience

Covid Resource Center (CRC)

Amazon (Aerotek) – Remote

August 2020 – Current

Serve as the support contact for employees with questions about their time away from work due to illness

Take ownership of employee contacts ensuring that each contact is accepted and resolved with a high degree of customer focus

Resolve queries by referring to documentation such as frequently asked questions and standard operating procedures and escalate when these cannot be resolved

Receive queries via phone or web case and log contacts into the shared service case management system

Handle customer absence claims end to end and contact customers to inform them of resolution, when appropriate

Assess new claims and make accurate classifications about the type of absence required

Navigate ambiguous claim requests and apply good judgement about how to apply policy and regulations to the case in question

Ensure all tasks and decisions are rendered within SLA

Claims Examiner

Meridian Health Plan (Totalmed - Remote) -Detroit, MI

May 2019 to March 2020

•Determine level of reimbursement based on established criteria, provider contract, plan and group provision for multiple products.

•Processes all eligible and ineligible for payment accurately and confirming to quality, production standard and specifications.

•Document provider claims/billing forms to support payment/decisions. Match authorizations to claims, maintain current desk procedurals and reference materials.

•Reviews appeals and complaints; researchers any missing or required information. Responds to providers or other company departments to process or resolve claim issue.

•identifies dual coverage, potential third party liability cases and reinsurance cases. Request additional information that is relevant to savings/recovery.

Account Representative

Intermedix (Addison Group)

May 2018 to December 2018

•Worked firsthand on actively reviewing patient accounts ensured claims were accurate and billable • Identified and resolved claim edits through understanding of billing guidelines and payer requirements

•Proactively fixed claim rejection errors and resubmitted claims based on payer requirements • Initiated contact and responded to inquiries from a various external sources • Complied with all government and third party payers regulatory mandated requirements for billing and collections

•Answered questions and assisted patients in regards to billing issues as needed • Ability to maintain confidentiality of all information under HIPPA guidelines

•Met departmental productivity and quality standards in timeframe given upon completion of training

Pharmacy Service Representative

CVS Speciality Drugs (Medix)

November 2017 to February 2018

•Used superb communication skills to contact doctor's offices and insurance companies to ensured in the accuracy of patient's specialty medication orders

•.Translated prescriptions and utilize your sig code knowledge

•Excellent data entry skills will aid in your success • Processed specialty medications in a timely manner

•Ensured all financial and clinical expectations were being met prior to fulfillment. Physical Therapy Medical Biller

Certified Reimbursement Solutions

February 2017 to October 2017

•Retrieving clinical documentation from Electronic Medial Records

•Preparing and submitting patient encounter claims

•Posting correctly paid claims from ERA's and paper EOB's into billing software • Identifying incorrectly paid claims and tagging them for follow up by the team biller accuracy and efficiency are important

Claims Analyst

Benesys

April 2016 to July 2016

Review claims for benefit determination based on exception reports of electronic claim

•submission or hard copy submissions

•Make corrections when necessary to incorrect participant or provider data

•Assist Client Services Representatives with difficult claim adjustments/corrections • Determine benefits for multiple groups and process claims accurately according to the corresponding plan documents

Medical Biller

Nuwell Medical Network

November 2015 to January 2016

•Charges Entry/Import/Scrub/Dashboards (i.e. Medicare IVR, Track Routers, etc) • Work Front/Back End Edits, take Patient Pays over the phone, post payments (Auto/Manual/Self Pay)

•Send Hard Copy Claims, work Unpaid Claims Report/AR/Appeals Add

Quality Improvement Outreach

Blue Cross Blue Shield of Michigan (Collabera) November 2014 to April 2015

•Performed in a contact center environment

•Processed calls to and from members

•Identified members with care gaps/HEDIS related health conditions and assists them in accessing care through plan benefits

Claims Recovery Specialist

Molina Healthcare of Michigan

November 2006 to September 2014

•Recover money as a result of an overpayment to a provider

•Voided claims out of QNXT

•Reprocess claims to the correct provider

•Adjusted claims to pay correctly according to the Medicaid fee schedule

•Paid claims to correct providers

•Coordinated and posted refund checks from providers

•Worked special projects

Coordination of Benefits

Molina Healthcare of Michigan

October 2005 to November 2006

•Resubmitted claims for correct payment

•Sent out letters requesting overpayment from providers

•Received incoming call from providers to resolve COB issues calls from doctors and solves problem with incorrectly paid claims • Did some outbound calls to providers or members for follow up with questions concerning claims

Claims Examiner/Call Center

Molina Healthcare of Michigan

October 2004 to October 2005

•Received incoming calls from doctors and solves problem with incorrectly paid claims • Did some outbound calls to providers or members for follow up with questions concerning claims • Reviewed high dollars (45,000 and over)accounts for other insurance and prepare for Advomas. • Investigated for other insurance

•Identified and tracked provider refunds and overpayments and research claims related issues

Claims Analyst/Provider Services

Health Plan of Michigan

March 2002 to October 2004

•Processed Medicaid claims from providers for payment

•Enter claims and assign claim numbers to ensure they are properly recorded on system • Decided whether authorization is needed for payment

•Received incoming calls from doctors and solves problem with incorrectly paid claims • Resolved coordination of benefits issues

•Knowledge has strengthened in health insurance (HMO) and medical terminology • Communication skills and providers skills has developed.

Claims Adjudicator

Selectcare

September 1999 to May 2001

•Adjudicated medical claims for payment

•Determined types of claims, benefit plan, and whether authorization was necessary • Resolved coordination of benefits issues • Entered referrals and patient contacts to ensure that authorizations were documented

•Resolved referral in order to release pends

•Entered claims and assigned claim numbers to ensure they were properly recorded on system • Sorted claims by medical plan number

•Reviewed medical billings and determined whether claims were payable

Education

Bachelors Degree

Davenport University

September 1995 to June 1998

Associates Degree in Health Care Technology

Davenport University

September 1993 to June 1995



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