Control Clerk Customer Service
Resume:
Barbara Trice-Green
**** ********** ** ************, ** 32209
*******.*****-*****@******.***
SUMMARY OF QUALIFICATIONS
Experience Healthcare and Customer Service advocate with over 30 years’ experience in the health insurance industry.
Skilled in several Florida Blue lines of business including: Medicare Advantage, Local, State, Medicare Payment Demand, Medicare, Nasco and Medical Records Unit.
Prioritize multiple tasks to ensure deadlines are met.
Proven ability to be flexible in a constant changing environment
Demonstrated excellences by ensuring timeliness goals are met.
PROFESSIONAL EXPERIENCE 2016-2022
Order Medical Records in a timely manner to meet the guidelines for BlueCard and the Escalation Association.
Escalation Association audit for HEDIS,RADV,OIG,MRA,CRA,HRADV
Performing manual research on Siebel,Diamond,RBMS,OCLI,IMS,PIMS,PAIS,QUEST,Availity and Imaginator systems
Working a spreadsheet for the Escalation process inputting the data that I gather from the different system, this Audit has highest priority.
Document the spreadsheet in detail on each process that was taken from ordering the medical records sending 2 medical records request in PAIS, creating SR, Client Letter, researching diamond, retrieving archive claims and Blue2.
Research and analyze documents in a timely manner.
INTERIM SERVICE ADVOCATE CLAIMS IV 2015
Responsible for understanding and determining the health order of liability (HOROL) by applying State and Federal legislative requirements.
Adjudicate claims through analysis of coordination of benefits laws to recover millions of dollars as a cost containment saving.
Responsible for analysis of medical claims based on medical terminology, hold codes, denial codes, ICD- 9 and ICD-10 diagnosis code
Minimize corporate risk through the proper and consistent application of Other Party Liability Guidelines and practices, as set forth by the National Associations of Insurance Commissioner.
Communicate with a variety of individuals insured’s, healthcare providers, other insurance carrier representatives for additional information.
Process high dollar claims which includes auto, worker compensation, supplemental insurance and other claims where a third party may exist.
OTHER PARTY LIABILITY – CONTROL CLERK
Updating the incoming files new and close
Research/Analyze/Interpret all incoming work
Loading new and return mail to the spreadsheet for inventory
Retrieve work from the WEB bin and sorting it for HMO, STATE, FEP, and Inquires Unit to insure the work is load to the appreciate area and work in a timely manner.
Client Letter
Purge file to make sure that we are in Compliance with Guide Well guidelines.
Technical Skills:
Aim
Claims Repository
Client Letter
Convergence
Diamond
Enterprise Image Processing
Medicare Payment Demand
IMS
Quest
RBMS
Sapphire
Siebel
Subrogation Database
Microsoft Suite ( word, excel, outlook, and power point )
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