Service Representative Claims Specialist
Resume:
**** ********** *** *******, ** *****
210-***-**** adwrc8@r.postjobfree.com
Gina A. Garcia
Objective:
To work in a challenging and rewarding position, that allows me to contribute to a team utilizing my skills, knowledge and abilities. Summary of Qualifications:
● Positive and enthusiastic work attitude
● Self- directed and responsible
● Experienced in building and maintaining customer service
● Advanced knowledge of Medicare/Medicaid, Managed Care and Workman's Comp guidelines
● Knowledge of ICD-9 and CPT coding
Work of Experience:
Molina Health Plan
Customer Service Representative II
Jan 2022 to Sept 2022
•Provides computer entries of authorization request/provider inquiries, such as eligibility and benefits verification, provider contracting status, diagnosis and treatment requests, coordination of benefits status determination, hospital census information regarding admissions and discharges, and billing codes.
Centene/Superior Health Plan
Dec 2018 to Jan 2022
Scheduling Programmer Coordinator I
•Handle PHI/HIPAA regulations and procedures
•Schedule home assessments for members who are wanting Personal Attendant Services to assist with home cleaning, and cooking.
•Schedule assessments for members who are wanting Day and Activity Health Services.
•Schedule home assessments for members wanting dental services, minor home modifications, respite services, or needing assistant living facility services.
•Verify primary care providers
•Verify eligibility of coverage with Superior Health Plan
•Submit authorizations for vendors
•Train new hires
•Update work processes
Work of Experience:
CGI Federal
May 2016- Dec 2018
Case Worker/ Document Support
● Review No-fault/ Workers Comp Claims appeals for Medicare
● Review all supporting documentation, payment logs, policy declarations
(policy limits) verifying and determining valid or invalid claims for reimbursement or refund.
● Disputing and dispositioning case by case
● Maintaining CMS guidelines and regulations to meet Medicare guidelines. Riverwalk OBGYN/ Nix Health care/ Provident Medical Management June 2015- May 2016
Billing/ Collections Specialist
● Process claims electronically and paper for various different insurances.
● Resubmit appeals, corrected claims and daily follow up online.
● Collections on old and current balances, mailing out balances and receipts on payments
● Posting payments and deposits daily.
● Calling insurance companies on a daily bases, receiving incoming calls from different insurance companies regarding claims.
● Collecting additional medical documentation for resubmission for appeals and denials.
● Communicating with patients regarding benefits, copays, deductibles and co-insurances.
● Assigned Insurances: Amerigroup, Aetna Medicaid and commercial, Superior Health Plan, TMHP, Molina Health Care, Cigna and Bcbs.
● Processed claims for different providers threw All Scripts, E-clinical, Athea, and Kereo
Corr Medical Billing
March 2015 - May 2015
Billing/ Collections Specialist
● Process claims threw Moms Program
● Work AR report daily, resolving denials
● Collect old balance accounts, and mail out monthly statements to patient with balance dues
● Enter Inpatient and Outpatients charges with appropriate coding, and billing demographics.
● Verified Insurance benefits by obtaining prior authorization/pre-certification.
● Post co-payments daily, insurance payments, and bank deposits daily Lk Jordan/ Centene/ San Antonio, Texas
October 2014 - February 2015
Senior Customer Service Rep II
● Receive and process incoming telephone requests, voicemails and emails from members, clients and pharmacies
● Log and track calls using help desk proprietary software
● Ensure that all Customer Services’ documents and databases are maintained accurately
● Participate as a member of the Customer-Centered Service Team, ensuring that all documentation is completed accurately
● Interview callers to gather information about the problem(s), and leads caller through to a successful problem resolution in reference to pharmacy benefit management claims
● Orient new staff members to the Call Center including an overview of HIPAA and department policies and procedures
● Coach and serve as a resource to others in the Call Center EO2 Concepts/San Antonio, Texas
June 2011-October 2014
Reimbursement Claims Specialist II/ Customer Service
● Review all incoming claims and related documentation for completeness; follow up on additional documentation to ensure “clean claim” submission and for case studies to include calling clinical caregivers to obtain the additional documentation.
● Enter required data and process orders in accordance with departmental procedure.
● Act as a contact person for Regional Account Managers, medical professionals, DME dealers and insurance companies to facilitate the organization of paperwork required for the processing of claims.
● Ensure all payer and internal requirements are met for each placement, proper documentation is kept and a copy is provided to the appropriate dealer.
● Notify appropriate person at dealer and/or internally of special claim processing instructions from payer.
● Track placement until internal and payer requirements are met for billing.
● Document and notify dealer and/or internal personnel of billing, pricing, and other claim-specific information.
● Ensures claims billed meet all governmental mandated procedures.
● Generates billing in a prompt and efficient manner.
● Coordinate and collaborate with Regional Account Managers and other team members to insure seamless process and customer service. KCI USA, INC/San Antonio, Texas
October 2003- August 2009
Coordinator of Patient Administrator Lead, Billing Medicaid Lead, PFS Senior Claims Specialist II, and Ship Pending Claims Specialist I and II
● Verified Insurance benefits by obtaining prior authorization/pre-certification.
● Entered Patient, coding, and billing demographics.
● Obtained all required information for billing, such as Letter of Medical Necessity and all clinical documentation to assist on denials and appeals for billing.
● Notified patients of their benefits and responsibilities.
● Worked unbilled reports to collect aged and present documents due, such as prescriptions, wound measurements and specific documents required by various insurances.
● Scheduled delivery and pick-ups on DME, canceling, and avoiding accounts.
● Team oriented and demonstrated supervisory ability. Sleep Diagnostic Services/San Antonio, Texas
December 2002-September 2003
Operator/Billing Coordinator
● Scheduled sleep studies, EEG appointments and handled multiple phone lines.
● Handled insurance concerns, including answering questions from patients and insurance companies and obtaining physician referrals.
● Followed up on denial claims.
● Posted and collected payments and arranged payment plans. Dr. Bell, Davis, Elder and Associates/San Antonio, Texas April 2000- November 2002
Office Manager/Optometrist Assistant
● Performed Office Manager Tasks for 4 locations.
● Processed bookkeeping and bank deposits on a daily basis.
● Scheduled appointments and handled multiple phone lines.
● Verification of insurance benefits and claims.
● Assisted doctor and educated patients about Laser Vision Corrections and different eye procedures.
● Performed Visual Field to check for glaucoma.
Education:
Thomas A Edison High School, San Antonio, TX 1995 Graduated Class of 95 San Antonio College, San Antonio, TX 1995 to 1997
Other Skills:
● Good communication skills
● Team player
● Windows, Word Excel, and Mac
● Works well under pressure
● Familiar with billing programs: Delair, MOMS, All Scripts, Athena, Kereo, Eclinical, Onbase, CAS
References
Sandra De Los Santos 210-***-****
Melissa Merritt (Supervisor EO2) 210-***-****
Justin Cypert (Supervisor EO2) 210-***-****
Rusty Adams (EO2) 210-***-****
Contact this candidate