JOHN R. BESS JR.

**** ******* ***, *** *** · Burlington, NC 27215· 908-***-**** (cell) · adxsjv@r.postjobfree.com

SUMMARY

Healthcare Provider Relations Consultant, Recovery, and Customer Service Specialist/Trainer with 15 years experience working within the customer service field and insurance industry (Commercial, Medicare, Medicaid, No Fault and Worker’s Compensation). Possess excellent written and verbal communication skills. Detail oriented with the ability to independently complete work accurately and in a timely and efficient manner. Contract management and compliance, online billing systems, Inventory, claims analysis, payment negotiations, provider education and retention, community relations, contract implementation and compliance are a central concentration for success.

EXPERIENCE

Health Business Solutions

Supervisor, Denial Recovery Claims

Supervise and manage the workload of on-site and remote DRS staff.

Establish claims par levels to meet workload requirements.

Tracked all samples given to staff and reported variances.

Monitor daily, weekly and monthly staff productivity reports.

Conduct payment audit and reporting activities for all clients.

Generate and analyze payment reports from staff and clients.

Develop and disseminate monthly payment file audit discrepancies reports.

Conduct project initiation account inventory reviews.

Develop job-aids or other supports to improve staff performance.

Prepare production and/or trending reports.

Monitor staff activity to ensure compliance to Standard Operating Procedures.

Inventory procurement and control; including audits.

Monthly client inventory and invoicing.

AT&T Communications, Bedminster, NJ

Contract Specialist/Independent Contractor

Contract implementation for AT&T BVOIP/MIS Services.

Contract maintenance.

Random Sampling for error identification.

Integrated Contract Tool (ICT) Report Monitoring.

Contract escalation reconciliation.

Coordinated Family Care

Executive Assistant/Office Manager

Provide oversight of daily office management.

Provide oversight for maintenance of agency assets/equipment.

Purchase service contracts in accordance with agency need for various types of agency equipment.

Provide direct supervision for administrative staff.

Develop and complete high-level correspondence (memos, public announcements).

Communicate appropriately with high-level public officials, corporate citizenry and other stakeholders (written and verbal).

Prepare detailed and visually sophisticated presentations and reports using Microsoft office applications.

Organize resources and talents of vendors, community stakeholders, public officials and other interested entities (i.e. newspapers) in staging high profile events.

Organize vendor relationships/services in accordance with organizational needs and requirements.

Create and maintain multiple filing systems and ensures that information contained therein is accurate and timely.

Attend/arrange staff and Board meetings; and records minutes in an accurate and timely manner.

Periodic support of CFC Board Committees and Workgroups.

Responsible for preparation and coordination of Board meetings and materials.

Manage, arrange and prepare Executive Director and Operations Manager calendars, travel itineraries

and daily schedule.

Provide simultaneous administrative support for Executive Director and Operations Manager.

Draft, compile and maintain monthly reports for 180 families.

Provide and maintain accurate and current information on community provider network and

disseminate this data to the organization as needed.

Cultivate and maintain professional relationships with community provider entities.

Identify service gaps within the community and take steps to minimize gap.

Effectively communicate the Mission of the organization internally and to families, providers and

community stakeholders.

Tri State Diagnostics Inc

Provider Relations Supervisor/Independent Contractor

•Draft appeals and denial responses and complaints to insurance companies.

•Filed NYS and NJ Insurance Department and Worker’s Compensation complaints, hearing requests, and HP-1’s.

•Database maintenance and management.

•Review and prepare insurance contracts and agreements.

•Prepare and submit provider participation applications.

•Negotiate insurance claims project payments/reimbursements.

•Resolve provider /insurance company issues/disputes.

•Research decisions and rulings appropriate to individual accounts/cases.

•Facilitated weekly production meetings with President and Operations Manager.

•Test Scheduling.

•Provider education and retention

ARC Group Associates, Jenkintown, PA

Recovery Specialist/Independent Contractor

•Medicare, Medicaid, commercial, hospital, and patient pay billing for government and commercial clients in PA, LA, FL, and NJ.

•Reviewed and verified UB04’s, HCFA 1500’s, and itemized bills for validity of denial reasons.

•Contacted various insurance companies, third parties, and patients regarding reconciliation of outstanding accounts.

•Input contracted allowances and received payments into the client system (HBOC/AS400).

•Identified and documented erroneous billing and coding trends and corrected claims prior to resubmission to insurance companies.

•Utilized and exhausted all means of recovery in addition to maintaining daily recovery records of collections on $2,000,000.00 project.

•Facilitated weekly updates on recovery efforts with director. (Efforts resulted in $1.7 million recovery of $2 million target of A/R in 1 month).

•Insurance/benefit verification/ CPT/ICD9 Code verification.

•Billing/ Oncology billing (electronic/paper Medicare, Medicaid, commercial, and self pay).

•Payment posting/Chart reviews/File maintenance.

Horizon/Mercy, Trenton, NJ

Provider Relations Consultant/Southern Counties

•Provide service for 1,236 network providers in Cumberland, Gloucester, Ocean, and Salem counties that includes Primary Care Physicians, Specialists, and Obstetricians/Gynecologists, not excluding hospitals and Federally Qualified Health Centers (FQHC) and recruited the same in accordance to specialty and network deficiency.

•Knowledge of NCQA guidelines.

•Seminar Presentations/In-office provider seminars.

•Provider Recruitment/Credentialing (Individual and group).

•File maintenance.

•Compose fee analysis/proposals for contract negotiation, Identified, investigated, and reported fraudulent trends and practices of providers and members.

•Review UB04's, CMS 1500’s, and itemized bills for coding errors and submitted as claims project.

•Resubmitted corrected claims projects for payment in accordance with policies and procedures.

•Calculated and applied fee reimbursement to suspended/appealed claims in accordance with RBRVS conversion method.

•Member/provider conflict resolution.

•Compile and utilize various reports and analysis to ensure success of the Network Operations Dept.

•Recruit healthcare providers in accordance to specialty and network deficiency.

•Identify, investigate, and report fraudulent trends and practices of providers and members.

•Assisted in the preparation of state responses to county deficiencies.

•Performed provider site reviews and medical chart reviews to ensure State Contract compliance.

ONE Health Plan of NJ

Call Center CSR

•Field mandatory requirement of 70 inbound calls per day

•Medical/Dental benefit determination/eligibility to members

•Inpatient/Outpatient Precertification

•Medical/Dental Claims payment and resolution

•Provider maintenance

SKILLS

ICD-9/CPT-4 Coding/ HCPCS

RVRBS Conversion (Relative Value Resource Based System),

Microsoft Office

Internet, Intranet

BEN, BES, BIL, CCS, PIMS, AS400, HBOC, OPTIMED, NEXTGEN,

EDUCATION

Paychex “Workplace Diversity Training” 2005

“Seven Habits of Highly Effective People ” (Stephen Covey) - 2001

H.I.P.P.A. Training 1999

Insurance Fraud Training 1999

Betty Owens Secretarial School, Paralegal Studies, 1990

U.S. Army (16E10/HAWK System) 1979 – 1985

Temple University, Communications, 1979

Contact this candidate