Medical Insurance
Resume:
Carla Harrington
Detroit, MI ***** ****************@*****.***
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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