Office Clerk Customer Service
Resume:
IRENE A JONES
**** * **** ****** *****, FL ***** Phone: 813-***-**** adwr3b@r.postjobfree.com
SUMMARY OF QUALIFICATIONS
Skilled in managing individuals in two different and distinct industries. Highly proficient in all phases of operations including: hiring, training, scheduling, performance management and record keeping. Proficient in gathering, analyzing and defining business and functional requirements; creating global metrics, trend charts and other decision-making tools; leading data-modeling and process-mapping initiatives; and designing/re-engineering processes and workflows. Proven ability to lead seamless implementations and deliver outstanding service by improving quality metrics and workplace productivity. Great time management and organizational skills.
PROFESSIONAL EXPERIENCE
WIPRO/CHANGE HEALTHCARE– TAMPA, FL
Contract Modeling Administrator 11/2010 to present
Analysis Facilities Insurance Payor Contracts and model contracts into a Proprietary system for auditing payment accuracy as a vendor for Hospitals.
Use Modeled Contracts to determine Payment Discrepancies, Trends and Appeal Opportunities for Improved Cycle Revenue.
Worked with technology liaison in development/ and enchantment of Proprietary contract modeling system.
CHAPIN – TAMPA, FL
Insurance Claims Auditor -Independent Contractor 4/2010 to 11/2010
Audited WellCare Payment for Florida Hospital’s for accuracy in payment to contracted rates for a legal proceeding.
UNITED HEALTHCARE– OLDSMAR, FL
Claims Operations Manager 3/2008 to 4/2010
Managed 180 employees and 6 supervisors located globally in initial claims processing or rework adjustments of physician, ancillary and facility medical claims along all Managed Care and Medicare supplemental products.
Improved turn time of rework processing at local site from 72% to 91.8% within 5 business days through implementation of improved process flows.
Documented workflows and executed comprehensive training plan to improve productivity and quality.
Gathered and assessed needs from internal business units; created custom solutions to resolve issues and developed service level agreements with the internal customer.
Automated manual, time-consuming processes, working with technology liaison in development of processing macros.
Member and Provider Appeal Supervisor 10/2005 to 3/2008
Supervised up to 30 appeals coordinators in the working of member, physician and facility appeals within regulatory guidelines.
Championed and organized a team to provide quality feedback on appeal response letters.
Served as subject matter expert on the creation of a web based tracking database for appeals.
Provide monthly coaching evaluations on quality and productivity metrics.
Claims Supervisor 4/2002 to 10/2005
Supervised up to 25 claim/ adjustment processors in the basic and complex medical claims.
Served as a subject matter expert on the development of a Windows based claims processing system and the development of the training documentation for both the processors and management of the supervisor workflow.
Provide monthly coaching evaluations on quality and productivity metrics.
Supervised the pilot team and served as subject matter expert on the implementation of pre-audit review process on new customer benefits.
Claims and Adjustment Specialist 11/1994 to 4/2002
Process basic and complex medical claims in various Managed Care, Indemnity and Medicare Supplemental plans for self funded and fully insured customers. Applied physician, ancillary and facility contract or reasonable and customary rates to payment of claims.
Resolved customer service inquiries including the request for benefits, eligibility status, provider networks and clarification of claims payment.
Mentored new hires and acted as a resource for training issues as a subject matter expert.
TAMPA EYE CLINIC- TAMPA, FL
Medical Office Clerk 7/1990 to 11/1991
Created and maintained patient files including insurance information and verification of benefits.
Scheduling of patient appointments.
Posted payments from insurance companies and patients.
THE HOME DEPOT– TAMPA, FL
Customer Service Supervisor 8/1984 to 11/1992
Responsible for hiring, training and scheduling for service and cashier staff of up to 50 individuals.
Facilitate meetings to encourage a positive work environment and share corporate communications.
Responsible for the balancing of cash drawers and daily deposits.
EDUCATION
Hillsborough Community College- Tampa, FL
Hillsborough High School- Tampa, FL
PROFESSIONAL SKILLS/ TRAINING
Microsoft Word, Excel, Visio and PowerPoint
Web/ Window based processing systems (CMS, TOPS, COMET, IDT, IDARS, etc.)
Behavioral Interviewing
Frontline Leadership
Leadership Essentials
Conflict Management
5 Dysfunctions of a Team
Building Trust in the Workplace
Kaset Customer Service Certification
Continuous Improvement and Effective Planning
Time Management
Stress Management
Delivery System Management- Problem Solving Methods and Tools
DMIAC- Six Sigma Methodology
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