Jacqueline Harris

**** ** **** ****.

Miami, FL *3142

Phone: 305-***-****

OBJECTIVE:

Obtain a challenging career position with a health care organization, which will effectively utilize my back ground, experience and skills.

SUMMARY OF QUALIFICATION:

• Extensive knowledge of claims processing guidelines including CPT, HCPC, ICD 9, Pre Existing and COB.

• Excellent communication skills.

• Strong motivational and research skills.

• Proficient in regulatory guidelines governing health plans. EXPERIENCES:

Nov 2010 – Present Molina Healthcare of Florida Miami, Florida Provider Inquiry Resolution & Research Representative II MFL Health Plan Op Job Summary

Provider Inquiry are responsible for the submission, research, and resolution of provider inquiries and disputes. They respond with the answer to all inquiries and coordinate with other Molina department as needed to resolve the issue, as well as to correct the underlying cause, the resolution are timely and in compliance with all regulatory requirements

Knowledge/Skills/Abilities

• Researches claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error.

• Resolves and prepares written response to incomings provider requests relating to claims payments for claim adjustments

• Completes appropriate documentation for tracking date; reviews data to assist with identifying potential provider problem areas.

• Variety of references to research and prepare healthcare provider information for loading into health plan system/database; enters provider demographics, contract affiliation, or other data as needed.

• Interfaces with other departments regarding questions about provider configuration or other provider issues.

• Maintain tracking system of correspondence and outcomes; maintain well organized accurate and complete files for all appeals

• Compose all correspondence and appeal information concisely and accurately, in accordance with regulatory requirements.

• Receive mail that’s been deliver to the mailroom every day. It goes to the MFL - Assoc Specialist, Appeals & Grievances, MFL Health Plan Ops team. It comes to me I open the envelopes separate and open, research sort them out by departments.

• File contract in the file room.

Appeals Clerk

• Triage and separate disputes by the date of receipt from each month for the entire inventory.

• Coordinate all provider complaints including working with Grievance and Appeals department to support and evaluate workflow provided in the appeals process.

• Review mail received and categorized for proper processing.

• Monitor Right fax and print documents received and distribute to the designated claims examiner.

• Provide the claims examiner with the required documents when requested also keep documents tracking safely stored.

• Review claims with W-9 and load W-9 into SharePoint accordingly.

• Maintain call tracks for the Provider disputes and Medicare disputes by keeping track of the Medicare disputes and updating the information in the AnG Database.

• Create and mail the Non-Contracted Medicare provider dispute acknowledgement letters.

• Provide assistance with other department on Member Moves by eligibility, address, term date, effective date.

July 2007 – Nov 2010 United HealthCare (Neighborhood Health Partnership) Miami, Florida

Claims Rep Assoc.

• Retrieve and review all incoming mails and faxes related to Claims Inquiries.

• Sort all claims (CMS 1500 or UB92) with attachments in categories and prepare them for scanning.

• Coordinate with other units within the departments to ensure timely resolution for providers/members issue.

• Participate in different tasks within the unit to ensure that the department meets its goal. April 2006- July 2007 Preferred Care Partners Miami, Florida Batch Processor

• Enter physician’s claims into batch screen and update the information.

• Review CPT and ICD 9 diagnosis and procedure codes for accuracy.

• Review claims on Laser Fiche before entering into medical management screen.

• Validate provider demographic information provided on claims, including Tax Identification information, to ensure proper payment.

June 2001- April 2006 Neighborhood Health Partnership Miami, Florida Claims Examiner

• Review HCFA 1500 forms before entering claims into Batch/Online entry screen.

• Return incomplete claims forms to providers.

• Enter physician’s claims into batch screen and update information.

• Review claims and select the appropriate affiliations for proper payment. June 1999-June 2001 Neighborhood Health Partnership Miami, Florida Team Leader

• Coordinates the work flow in the mailroom on a daily basis.

• Distribute all batched claims to supervisors as needed.

• Sort and batch all priority claims and deliver to proper personnel.

• Assist in distributing claim reports within the department.

• Maintaining a turnaround time in the mailroom no more than 2 days. October 1998- June 1999 Neighborhood Health Partnership Miami, Florida

(Creative Staffing)

Administrative Clerk

• Open and sort mail in different categories.

• Microfilm all mail within a timely manner.

• Clean machines as needed to ensure claim numbers are clear and readable.

• Pick up and distribute all reports from the Printer Room and distribute to individuals within the Claims department.

EDUCATION:

1981- 1985 American Senior High School Miami, Florida

(Graduated June 1985)

REFERENCES:

Available upon request

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