KAYLA COX

K

Raleigh,NC

984-***-****

adu7ez@r.postjobfree.com

A young goal-oriented customer service, healthcare and administrative professional with 6+ years of solid experience and a successful track record. An individual highly skilled at handling all aspects of customer and client interaction who consistently strives for excellence while demonstrating superb interpersonal skills. A self-motivated team player with excellent communication skills who understand the importance of being available as scheduled to assist the Company in achieving its overall mission.

WORK EXPERIENCE

Quality Assurance Processor I

01/2023 to Present

Ciox Health

Remote

responsible for ensuring the integrity of the information that is received into ECS s database is accurate and compliant with client and Company policies and expectations. Furthermore, they will be responsible for verifying the integrity of the information, skillset and understanding of role by the Field Tech. Review and Evaluate each assigned chart per compliance specifications Identify and calculate specific measures have been retrieved within a chart Assess and recommend best practices as applied to each retrieved medical record to prevent PHI violations and to ensure Client satisfaction

Identify any obvious deficiencies with a chart retrieval per tech Document trend observations appropriately and escalate urgent issues to Team lead Understand Company and Client objectives to optimize the success of each project Expand list of responsibilities as knowledge and business growth increase Short Term Disabilty Claims

10/2022 to 12/2022

Metlife

Remote

Effectively manages with some level of oversight an assigned caseload of moderately complex claims which consists of pending, ongoing/active and appeal reviews. The LTD CS will be evaluated for increases in their authority levels as they become more experienced in their decision-making and demonstrate consistency in meeting all key performance indicators Provides timely, balanced and accurate claims reviews, documentation and recommended decisions in a time sensitive and fast-paced environment and in accordance with state and department of insurance regulations Provides frequent, proactive verbal communication with our claimants and/or their representatives demonstrating empathy and active listening while providing clear updates, direction and explanations regarding the claim process, benefits and other pertinent plan provisions. These calls are used to gather essential details regarding medical condition(s) and treatment, occupational demands, financial information and any other information that may be pertinent to the evaluation of the claim. Once telephone calls are completed, you will be required to document the conversation within the claim file in a timely manner utilizing the appropriate level of detail and professional writing skills Interacts and communicates effectively with claimants, customers, attorneys, brokers, and family members during claim evaluations

Compiles file documentation and correspondence requiring extensive policy and factual detail. Analyzes information to determine if additional information is needed to make a reasonable and logical claims determination based off the information available

Collaborates with both external and internal resources, such as physicians, attorneys, clinical/ vocational consultants as needed to gather data such as medical/occupational information in order to ensure reasonable, thorough decisions. Clarifies and reconciles inconsistencies when gathering information during claim evaluations and collaborates with Fraud Waste and Abuse resources

Patient Financial Services Representative

08/2021 to 09/2022

North American Partners of Anesthesia

Remote

Request and validate the account information necessary for billing and claim submission. This may include primary and secondary insurance information, patient s legal name, billing guarantor, current address and telephone number. Make every effort to fully resolve issues at time of the inquiry. Escalation of accounts is appropriate only when Associate is unable to resolve issues. Refer to department guidelines for required actions. Handle client complaints in a professional manner, following all policies and procedures. In the event a patient/parent disputes the billed amount or validity of services, attempt a resolution; but if caller remains dissatisfied, advise of the right to file a formal, written billing dispute in accordance with policy/ procedure. Verify 3 separate elements of the patient account including the patient s date of birth, prior to speaking with clients. Elevate problems or trends to the department s Management Ensure weekly review of the MedData Accumulation file in Medsuite is conducted weekly for each practice Report any trends or errors from accumulation to improve processing of the accumulation files. Program Specialist

10/2020 to 07/2021

Biogen

Remote

Biogen MS & Gilead Advancing Access -Quickly and efficiently respond to incoming calls and faxes,identify how best to assist. Document calls in appropriate tracking systems i.e Siebel Financial Services, Salesforce . handle/escalate calls per established procedures. Conduct insurance verifications to understand if patient s prescribed therapy is eligible for coverage. Coordinate prior authorizations, investigate alternative insurance coverage, or other funding sources on behalf of the patients per the program specifications. Process patient applications of various complexities, and follow the programs specifications to determine their eligibility. Place follow up calls and respond to enquiries from patients and/or healthcare providers as necessary. Liaise with partner distributors and pharmaceutical manufacturers to request products per the program s guidelines and track shipments .Coordinate the order and transfer of prescriptions based on their degrees of urgency to specialty pharmacies as appropriate. Be familiar with the market place and the insurance options available for patients.

Revenue Cycle Financial Representative

07/2019 to 08/2020

UNC Health

Chapel Hill,NC

Responsible for a variety of complex pre-services,financial navigation and customer service related functions for patients and/or their representative including pre-service estimates, collection of pre payments and prior debt,,obtain authorizations, address billing questions, establish payment plans, screen for financial assistance programs, respond to patient billing inquiries and other Customer Service requests for both hospital and physician services. Create Hospital and Physician estimates using the Epic Patient Estimator, review eligibility and benefits utilizing RTE and payer websites, and obtain authorization requirements. Contact patient pre-service providing benefit and patient liability education,explain the estimate cost,and attempt to secure payment and/or set expectation of payment at time of service. Obtain patient signatures on fee agreements, ABN, and waivers as appropriate. Provide estimates to patient shoppers and clinical areas across the healthcare system. Serve as a liaison between clinical areas and patient financial services.. Screen and assist patients with financial assistance programs including UNC Financial Assistance, Medicaid, COBRA Assistance, ACA plans and/or other funding sources available. Monitor and track routine follow up with Medicaid and financial assistance approvals. Assist with processing financial assistance applications to decision as appropriate. Handle HB/PB patient inquiries to address any/all billing questions via inbound calls, MyChart,patient correspondence and patient walk-ins. Fulfill patient requests for itemization of charges,adding/ verifying/billing insurance,establishing payment plans,payroll deductions, process adjustments,request refunds,and explain financial assistance policy and guidelines. Work with Patient Relations,Risk Management for HB and PB patients who have escalated complaints or concerns. Patient Financial Representative

04/2019 to 07/2019

American Anesthesiology

Raleigh,NC

Provide customers and external business partners with accurate information and account status. This requires thorough review of Medsuite and MedData Portal; review of Account Notes; review of EOB s and/or any other correspondence received and accurate assessment of new and/or revised information provided. Request and validate the account information necessary for billing and claim submission. This may include primary and secondary insurance information, patient s legal name, billing guarantor, current address and telephone number. Make every effort to fully resolve issues at time of the inquiry. Escalation of accounts is appropriate only when Associate is unable to resolve issues. Refer to department guidelines for required actions. Handle client complaints in a professional manner, following all policies and procedures. In the event a patient/parent disputes the billed amount or validity of services, Patient Engagement Specialist

02/2017 to 04/2019

Duke Health

Durham,NC

Served as a member of the Patient Revenue Management Organization (PRMO) team. Answer and resolve all inbound inquiries and issues regarding patient account statements, debt write off’s, explanation of benefits, balance due, and other patient and insurance billing related scenarios. Analyze patient s issues that are presented by collecting information, data and conducting thorough research using the Epic patient accounting systems, Blue E and Hyland Onbase systems for documents that are imaged such as (EOB s, statements, admitting documentation, patient correspondence,etc.) for eligibility, researching payor websites and/or contacting the payor as needed. Analyze information for appropriate solution and take the necessary action needed to resolve the issues. Follow through on all customer issues promptly and accurately until completion. Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics. Document reason for call includes issues that are tracked and followed up via Customer Relationship Management(CRM). Thoroughly update and document CRM with all information pertaining to an inquiry (i.e. questions, answers, actions, follow up items required). Communicate with the patient, physicians, collection agency, Veterans, internal departments and all other internal and external customers in a professional, courteous, and respectful manner.

CSR - Customer Service Representative

04/2016 to 12/2016

Blue Cross Blue Shield

Durham, NC

Acted as a service relationship management professional for Blue Cross Blue Shield of North Carolina (BCBSNC) customers, employer groups and providers to successfully service healthcare insurance needs. Provided consistent, reliable and customized stakeholder service interactions in a highly efficient and effective manner. Strengthened the BCBSNC brand by developing, managing and expanding customer relationships at service levels that meet and exceed customer expectations.

Supported and be committed to the mission, vision and values of the company by delivering seamless, energetic and innovative service solutions to increase stakeholder satisfaction and retain customers.Utilized probing and creative problem solving methods to resolve foundational customer inquiries on first contact. Documented corrective measures and provide instructions as needed to internal business areas to ensure prompt resolution and response to customer inquiries. Identified and obtained information and records from customers, members, providers and/or employer groups to correct/update information, claims and membership records when necessary. Recognized patterns of inconsistent and inaccurate claims filing practices among customers and providers, educated customers and providers on acceptable BCBSNC practices and policies. Performed phone and email outreach to BCBSNC vendors and business partners to resolve service issues. Worked collaboratively with Sales, Healthcare and Network Management partners to further optimize customer, employer group and provider relations by identifying opportunities to promote stakeholder programs. Customer Service Representative

02/2013 to 12/2015

Total Outsourced Systems

Raleigh,NC

Trained to enhance the level of customer satisfaction by adjusting to the personality of your customer whilst assisting them in planning, installing, training, trouble-shooting, maintaining, upgrading and/or disposing of a product. The correct use of a product throughout its life cycle is essential in generating returning customers and good references by using Customer Relationship Management Systems (CRM)

Interacted by inbound phone calls received to the Call Center, build rapport with customers by greeting them in a courteous, friendly, and professional manner. Handled and resolved customers’ inquiries and complaints, or route calls to appropriate person or department, records information regarding calls into a database. Prepared complete and accurate work and updated customer file, data entry, process orders and accounts. Ensured that customers understand product information, and be able to provide additional information to customers as needed Customer Service & Sales Representative

10/2006 to 10/2007

Michaels Arts & Crafts

Raleigh,nc

Provided fast, easy, flexible and friendly service to our customers. " Greeted, smiled and provided prompt, accurate and friendly service while engaging customers to create a positive shopping experience. "Processed sales transactions by operating registers; scanning and verifying product information in register; bagging merchandise; and adjusting to different types of transactions according to company guidelines. Accurately handled all monies and tender to insure proper accounting of all transactions. Properly bag guests orders, place in cart or hand to guest, and follow the carryout practices. Work well with all team members to grow community. Continually maintain clean work area. Directed guests into his/her lane to maintain guest flow and maintained cash controls and procedures. Performed all cash register operations and related customer service duties. Monitored activities in the front of the store and secures Michaels assets including cash, checks, media and merchandise. In addition to providing world class service to our customers performed all other duties as assigned by management.

SKILLS

Microsoft office

Epic

CRM

Athena Health

Medsuite

Chartfinder

Microsoft Teams

Insurance Verification

Financial Services

Medical Terminology

Billing

Customer Service

Data Entry

EDUCATION

North Carolina Central University

Bachelor’s

Public Health

Durham NC

Wake Forest -Rolesville High

High school or equivalent

General Studies

Wake Forest

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