Support Representative Care

Tomekia L. Gordon-Aldridge

**** ***** *****

Indianapolis, IN 46268

317-***-****; ***********@*****.***

CAREER OBJECTIVE

To maximize my team leading experience in a challenging environment, guiding by example and utilizing vast experience in directing a team towards its objectives within deadlines and thus achieving the corporate goals.

SUMMARY OF QUALIFICATIONS

●Detailed experience with Revenue Cycle Operations in the Healthcare environment

●Experience developing and maintaining positive customer/client relations and coordinating with various functions within the company/department to ensure customer requests are handled in a timely manner

●Knowledge of claim submission guidelines for all payers to include commercial and government products with an understanding of Medical Terminology, ICD-9, CPT and HCPCS codes

●Expert with the CMS-1500 and UB04 billing format, CIF Process, and knowledge of current regulatory requirements

●Experience reconciling and balancing accounts for annuity and health policies

●Able to effectively analyze business needs and develop/implement strategies to gain efficiencies and meet corporate goals by eliminating annuity disbursement errors for withdrawals, surrenders, required minimum distributions, and death benefits

●Qualified to provide departmental leadership, including training to enhance staff knowledge and improve productivity

●Excellent oral and written communication/presentation skills

●Experience providing feedback and new ideas to administration, management and clinical staff on claim issues associated with reimbursement

●Certificate and knowledge in Human Resources policies and procedures and payroll

●Microsoft Office Certified

●Licensed in Health, Life, and Accident for the State of Indiana

PROFESSIONAL EXPERIENCE

Dec 2022 – Present Westpark A Waters Community Business Office Manager

Execute business office functions specific to geriatric and adult residents associated with physical, cognitive, and socialization factors.

Conducts collection calls on delinquent accounts with letter documenting all actions.

Resolves balance disputes as needed/requested from responsible parties/residents.

Follows Medicare procedures as needed or on a weekly basis, reviews Medicaid pending conversions on a weekly basis, or as needed.

Conducts follow-up with county caseworkers regarding status of application, conducts follow-up with resident/responsible party regarding status of application and compliance, and advise resident’s Social Worker and Administrator of potential problems as they arise.

Gather month-end medical reports and maintains file for reporting and ensures timely responses to Medicare requests for medical records.

Reviews Medicaid authorized new admissions on a weekly basis, or as needed and ensures proper notification is sent to local department of Social Services regarding Medicaid admission to facility.

Prepares daily deposits, and makes deposit at the bank, verifies appropriate monies are being deducted for personal accounts on Medicaid residents, and advises Administrator whenever there is a discrepancy.

Supervises Business Office Staff and conducts regular meetings to review progress toward departmental goals.

Conducts all Human Resource functions such as hiring, onboarding, disciplinary conduct reviews, employee evaluations, entering and processing payroll.

Communicate and observe the Corporate Compliance Program effectively and complies with Code of Conduct when performing work functions.

Mar 2021 – Dec 2022 Sedgwick Claims Management Services Disability Examiner

Analyzes, approves and authorizes assigned claims and determines benefits due pursuant to a disability plan.

Reviews and analyzes complex medical information (i.e. diagnostic tests, office notes, operative reports, etc.) to determine if the claimant is disabled as defined by the disability plan.

Utilizes the appropriate clinical resources in case assessment (i.e. duration guidelines, in-house clinicians).

Communicates with the claimants’ providers to set expectations regarding return to work.

Determines benefits due, makes timely claims payments/approvals and adjustments for workers compensation, Social Security Disability Income (SSDI), and other disability offsets.

Medically manages disability claims ensuring compliance with duration control guidelines and plan provisions.

Communicates clearly with claimant and client on all aspects of claims process either by phone and/or written correspondence.

Informs claimants of documentation required to process claims, required time frames, payment information and claims status either by phone, written correspondence and/or claims system.

Coordinates investigative efforts ensuring appropriateness; provides thorough review of contested claims.

Evaluates and arranges appropriate referral of claims to outside vendors or physician advisor reviews, surveillance, independent medical evaluation, functional capability evaluation, and/or related disability activities.

Negotiates return to work with or without job accommodations via the claimants’ physician and employer.

Aimed to provide clients and claimants with the highest level of customer service possible.

Oct 2020 – Feb 2021 Accredo Health Group Eligibility Representative

Process specialty pharmacy claims for specialty medications verifying pharmacy and medical benefits.

Handle multiple requests while accurately documenting information from conversations with patients and doctors offices.

Research insurance issues on benefits coverage with pharmacist and doctors’ offices and provide guidance to the patients about medication coverage.

Advanced knowledge of benefits verification, problem-solving skills with the support of my team to resolve patients’ concerns effectively.

Coordinate and ensure services provided will be reimbursable by talking to patients about their deductibles, co-payments, and authorizations.

Updated all member data regularly and carefully inputted insurance and demographic changes into company’s computer system.

Reduced financial discrepancies by accurately resolving billing issues while processing applications and cancellations.

Aided management by generating daily inventory reports to ensure turnaround times were met.

Worked with team members maintain production within standard turnaround time.

Feb 2019 – Oct 2020 Bluegreen Vacation Owner Services Specialist

Maintains complete subject matter expertise relating to all Bluegreen Vacation Club policies, procedures and system fulfillment in order to serve as a mentor and peer group advisor within Club Services.

Supports more complicated call types and maintains product details when handling a limited volume of calls.

Maintains excellent communication skills, both verbal and written, to support both Agent and customer calls with an extremely high degree of service quality.

Handles escalated calls by first addressing the customer’s emotional state and needs, and then managing the program information communication that is required to resolve the situation.

Supports unique requests to assist with urgent servicing issues that may require additional research and facilitating difficult conversations with customers. Assumes full ownership of unique situations as a triage resource for the floor.

Masters usage of business tools and quickly navigates multiple systems, such as SalesForce.com and BOSS, to support business documentation protocol and drive compliance amongst all Club Services staff.

Bluegreen Vacation Senior Vacation Specialist

Answered inbound phone calls assisting guests in booking, canceling and rescheduling reservations.

Utilized sales techniques to sell new vacation packages, additional vacation enhancements, and upgrades all while creating happiness for the owners.

Effectively resolved any guests’ issues or concerns by providing resolutions on the first call.

Finance Specialist

Assisted Financial Analyst with routine analysis, forecasting, management reports and research, which includes areas such as expense variance, depreciation, capital expenditures.

Assisted in preparing budgets, short and long-term forecasts, trend analysis and expense accruals.

Tracked key performance indicators and elevate possible threats/risks, along with recommended actions.

Review of spending and explanation commentary, in regard to actual to budget, forecast and prior year comparisons on a monthly basis.

Compiled and distributed various monthly financial reports with variance commentary, along with conducting ad hoc reports upon request.

Partnered with Corporate Accounting & Finance to contribute information for various monthly journal entries and monthly financial close efforts.

Sept 2018 – Aug 2019 Lincoln Heritage Field Agent

Build clientele through given leads given via website inquiries and mail.

Obtain new business through policies written

Provide excellent customer service, a positive attitude, and a willingness to help people meet their insurance needs

June 2014 – June 2019 Fedex Service Center Support Representative

• Performed administrative/clerical functions, including but not limited to, maintaining files, copying, imaging, answering phones, data entry, sorting/ distributing mail and/or packages.

• Provided accurate information and assistance to customers, which included determining pick-up and/or delivery needs, problem resolution, updating systems to meet customer special handling requirements, selling company services and provide potential leads to sales.

• Entered freight shipment information into computer system.

• Administered freight pick-up process.

• Assisted customers via phone, e-mail and/or fax in all inquiries.

• Made freight delivery appointments.

• Reviewed drivers’ logs to ensure accuracy, report discrepancies to appropriate leadership member.

• Assisted city operations.

• Communicated with sales, operations and other service centers and/or departments to ensure customer’s needs are achieved and all issues are resolved.

• Reconciled cash and checks collected, prepared deposits and COD check remittance to customers.

Dec 2012 – Feb 2019 Fairfield Inn & Suites by Marriott Assistant General Manager

●Assisted the General Manager in the overall success of the hotel by meeting or exceeding planned objectives in an effort to maintain maximum occupancy, revenue, efficiency and accuracy.

●Ensured superior service is provided to all guests and product quality standards are met.

●Oversaw the hotel in the absence of the General Manager.

●Interviewed, hired, and trained employees in assigned departments. Reviewed employee performance and conducted personnel actions such as disciplinary actions and terminations.

●Addressed guest concerns and resolved problems.

●Responsible for administrative reporting. Maintained accurate records including cash flows sheet, guest floor limit, AR Ageing reports, and direct billing

●Assisted with revenue management. Primary function is to aid the general manager with paperwork and similar administrative duties. This included accounting-related functions like approving and submitting vendor invoices, reconciling account receivables, completing bank deposits and cash bank audits.

●Analyze and evaluate the hotel’s performance through data compilation of occupancy and labor reports as well as the guest satisfaction index.

●Oversee guest services, ensuring that superior service is a priority.

Feb 2016 - Sept 2016 That’s Good HR at SCA Insurance Verification Analyst

●Verified insurance prior to the patient’s surgery or procedure, demographic information and updated when necessary.

●Identified the patient’s primary, secondary and sometimes tertiary insurance coverage, contacted insurance companies to verify coverage, benefits, and eligibility.

●Verified payer selected matched plan type based on information provided by the insurance company.

●Identified the difference between precertification and referral.

●Communicated financial responsibility to patient and made arrangements for them to pay amounts necessary.

●Achieved defined metrics.

Sept 2014 - Sept 2015 KForce Staffing at IU Health Patient Financial Analyst

●Prepared and submitted claims to Government Intermediaries for all Medicare and Medicaid programs, Secondary Payers, and patients for the Radiology department, in an accurate and timely manner.

●Performed and executed various functions to complete and expedite the billing process including, electronic and hardcopy billing, recording patient identification data and physician diagnosis, investigating charges, correcting and updating data, preparing the claim to bill, and updating computer functions.

●Tracked progress of program and prepared status reports to management or senior management.

●Identified and reported billing issues to management and clients as appropriate

●Received/processed insurance updates and initiated paperwork for refunds as needed

●Made written and/or verbal inquiries to offices or third-party payers to reconcile patient accounts.

●Processed and distributed HCFA 1500's and MA claim forms as required.

Mar 2014 -- Jun 2014 Fresenius Medical Care Patient Account Representative

●Accurate and timely receipt of claim payments and minimization of unexpected bad debt by monitoring assigned worklists, working with the appropriate clinical, regional and divisional staff to resolve related issues.

●Generates and monitors all work lists specific to the Collections Role.

● Identifies need for insurance changes and completes required forms to initiate request, transfers balances to correct payer, initiates re-bill of unpaid or underpaid claims, processes noncash related adjustments per established guidelines, and initiates appeal requests per payer guidelines.

Sept 2009 – Mar 2014 St. Vincent Health Denial Management Representative

●Accurate and timely preparation and submission of claims to Government Intermediaries for all Medicare and Medicaid programs, Secondary Payers, and patients for all St. Vincent stress centers.

●Served as a team lead responsible for consulting with providers to improve the effectiveness and efficiencies of provider practices.

●Performed and executed various functions to complete and expedite the billing process including, electronic and hardcopy billing, recording patient identification data and physician diagnosis, investigating charges, correcting and updating data, preparing the claim to bill, and updating computer functions.

●Tracked progress of program and prepared status reports to management or senior management.

●Identified and reported billing issues to management and clients as appropriate

●Received/processed insurance updates and initiated paperwork for refunds as needed

●Made written and/or verbal inquiries to offices or third-party payers to reconcile patient accounts.

●Processed and distributed HCFA 1500's and MA claim forms as required.

May 2009 – Sept 2009 That’s Good HR Staffing St. Vincent Health – Financial Representative

●Accurate and timely preparation, submission and follow up of claims to Government Intermediaries, Secondary Payers, and patients.

●NOTE: Job performance as a temporary associate led to permanent placement and added duties (see job description above)

Mar 2009 – May 2009 Street Links Order Processor

●Processed appraisal orders from banks by contacting real estate agents in national database in a high volume, deadline driven environment.

●Assigned new appraisal orders to approved appraisal vendors per research.

●Recruited and hired new appraisal vendors.

●Confirmed appraisal vendor compliance with all licensing and certification requirements for state and applicable regulatory agencies.

Nov 2006 – Mar 2009 WellPoint Customer Care Representative II / Team Lead

●Responded timely to customer questions via telephone and written correspondence regarding Medicaid benefits, provider contracts, eligibility, and claims in a fast paced, inbound call center.

●Analyzed problems and provided information/solutions for the entire team.

●Researched and analyzed data to address operational challenges and customer service issues. Provided external and internal customers with requested information.

●Reviewed appeals and grievances for denied claims, gave information, and forwarded to appropriate department for review of necessity.

●Trained new hires on all processes.

●Team lead for a team of 23 associates.

●Managed at a minimum of fifty inbound calls daily.

●Entrusted with the most complex customer service issues as a result of exceptional ability to promptly resolve concerns and satisfy customers with sensitive issues pertaining to claims, grievances and appeals.

EDUCATION

Marion College Indianapolis, IN

Human Resource Management, BA Oct 2007 – Aug 2009

Indiana Wesleyan University Indianapolis, IN

Health Care Management MBA Jan 2010 – Nov 2011

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