Customer Advocate Claims Examiner
Resume:
TERRIE DRAUGHN
***********@*****.***
OBJECTIVE
To obtain a position within a company with an opportunity for growth. EXPERIENCE
AmeriHealth Caritas, Philadelphia, PA (2018-Present) Credentialing Technician
● Screen the applications and supporting documents of practitioners and facility to ascertain their eligibility.
● Update addresses of providers by adding or terminating locations.
● Update provider status by enrolling or terminating files.
● Responsible for the preparation of provider applications for the purposes of credentialing and re-credentialing.
● Collect information from National Practitioner Data Bank (NPD) for the applicant, malpractice insurer and other relevant sources.
● Identify discrepancies in information and conduct follow-ups.
● Presents applications to the facility credentialing committee.
● Respond to health plan provider inquires and assist with credentialing inquiries.
● Capture primary source documentation in databases.
● Ensure data is back up and saved.
AmeriHealth Caritas, Philadelphia, PA (2017-2018)
Claims Examiner
● Applied established protocols to ensure resolution is provided and presented in a clear and accurate manner.
● Met or exceeded all department standards: productivity; quality; and attendance.
● Responsible for resolving a high volume of claims edits for all lines of business.
● Thorough understanding of authorizations, benefits, contracts, enrollment and fee schedules.
● Price claimed using external vendor processing systems and manually apply rates in the core system.
● Resolution of complex and high dollar claims.
● Ensured accuracy and timeliness of claims processing to minimize late payment interest penalties and ensure compliance with established guidelines.
● Demonstrated solid judgment and discretion working with confidential information.
● Complied with all department and company guidelines including all applicable laws and regulations.
● Demonstrated ability to perform independently in conformance with written instructions, established timeframes, and pre-determined priorities.
● Adjusted claims and examined authorizations.
AmeriHealth Caritas, Philadelphia, PA (2013-2017)
Member/Provider Services
● Serviced calls and correspondence from members and/or providers; identifies and/or responds to inquiries, dissatisfaction, complaints and grievances.
● Applied established protocols to ensure resolution is provided and presented in a clear and accurate manner.
● Facilitated problem resolution and acts as a customer advocate.
● Accurately and concisely documents customer responses in the health care system.
● Researched member/provider and/or enrollment issues utilizing department procedures, reference materials and internal and external systems.
● Accurately updates member/provider information in all appropriate systems.
● Utilized AT&T Language Line and the Telecommunications Digital Device (TDD) when necessary to service non- English speaking or hearing impaired members.
C.A.D.E.S, Swarthmore, PA (2012-2013)
DSP, Residential Program
● Provided care for clients such as assisting with hygiene, meals, and medications.
● Organized social gathering for clients.
Community Interactions Swarthmore, PA (2008-2012)
CSA II, Day Program
● Organized daily outings and in-house activities for consumers.
● Assisted with client adaptation in social situations.
● Taught consumers with mental disabilities how to function and to learn independently. Belvedere Nursing Home, Chester, PA (2007-2008)
CNA
● Assisted residents with hygiene, feeding, taking vitals, in addition to other general aid.
● Transported clients to healthcare appointments.
● Venipuncture
● Urine Collection
● Finger Sticks
Sterling Nursing Home, Media, PA (2005-2007)
CNA
● Assisted residents with hygiene, feeding, taking vitals, in addition to other general aid.
● Transported clients to healthcare appointments.
● Venipuncture
● Urine Collection
● Finger Sticks
EDUCATION
COMMUNITY COLLEGE OF PHILADELPHIA
Studied Psychology
CHESTER HIGH SCHOOL, CHESTER, PA (1994-1999)
High School Diploma, English Major
CERTIFICATIONS
● First Aid Certified
● CPR Certified
● Fire Safety Certified
● CNA Certified
● NPCE Phlebotomy Certification
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