Service Representative Enrollment
Resume:
Caletha Jones
Hallandale Beach, FL 33009
adxvt7@r.postjobfree.com
Objective: To obtain an Insurance Coder/Medical Billing/Administrative position with a Hospital, Physician’s office, or other Health Care Facility.
Pertinent Skills
Medical Billing: CPT-4 Coding, ICD-9 Coding, Coding-Anesthesia, Surgery, Radiology, Pathology and Medicine Services; Keyboarding, Medical Office Procedure and Medical Manager Software
The Jacobson Group Temp Agency
Benefit Enrollment Representative November 2021 - January 2022
Humana Insurance Project
100% Remote Position
*Answer incoming provider and member calls
*Verify Veteran Member Enrollment and Eligibility
*General Claims Processing
Maximus
New York Vaccination Project January 2021 - April 2021
100% Remote Position
* Answer incoming calls from citizens related to COVID-19, including the general public. Schedule Appointments, Verify Appointments, Cancel Appointments, and locate nearest Vaccination sites within clients location.
Maximus
Customer Service Contact Tracer Project June 2020-December 2020
100% Remote Position
* Answer incoming calls from citizens related to COVID-19, including the general public. Make outgoing calls to those identified to have had contact with an individual who tested positive for COVID-19 in accordance with all performance standards, policy and procedures, and protocols.
* Transfer/refer citizens to appropriate entities according to the established guidelines.Respond to all inquiries consistent with confidentiality and privacy policies and refer callers to alternate sources when appropriate.
* Escalate calls or issues to the appropriate designated staff for resolution as needed.Track and document all inquiries using the applicable systems.
* Facilitate translation services for non-English speaking callers according to procedures.Attends meetings and training as requested and maintains up-to-date knowledge of all programs and systems.
* Respond effectively to all forms of inbound and outbound contacts, provide responses to questions,and in specific instances, refer callers to the appropriate supervisor, county, or state agency representatives for service and/or when problems or concerns occur.
* Investigate and resolve complex and escalated issues resulting from multiple
* Maintain updated knowledge of the program including its policies and procedures.
Caletha Linen Lady
Event/Decor Party Rentals
Owner established 2010 – 3/2020
Specializing in Party Rental Decor
Aetna/Coventry Health Care
13640 Concord Terrace
Sunrise, FL 33345
Inbound/Outbound Queue Associate 2007 – 2018
*Performs intake of calls from members or providers regarding services via telephone, fax, EDI. Utilizes eTUMS and other Aetna systems to build, research and enter member information.
*Screens requests for appropriate referral to medical services staff.
*Approve services that do not require a medical review in
Accordance to the benefit plan.
*Performs non-medical research including eligibility verification, COB, and benefits verification.
*Maintains accurate and complete documentation of required information that meets risk management, regulatory, and
accreditation requirements.
*Promotes communication, both internally and externally to enhance effectiveness of medical management services (e.g., claim administrators, Plan Sponsors, and third party payers as well as member, family, and health care team members respectively) *Protects the confidentiality of member information and adheres to company policies regarding confidentiality.
*Communicate with Aetna Case Managers, when processing transactions for members active in this Program.
*Supports the administration of the precertification process in compliance with various laws and regulations, URAQ and/or NCQA standards, where applicable, while adhering to company policy and procedures.
*Places outbound calls to providers under the direction of Medical Management Nurses to obtain clinical information for approval of medical authorizations.
*Uses Aetna Systems such as QNXT, ProFAX, ProPAT, and Milliman Criteria.
*Communicates with Aetna Nurses and Medical Directors, when processing transactions for members active in this Program.
Customer Communication Specialist 2005-2006
*Interface with customers via telephone, written correspondence, and fax to respond to inquiries and resolve concerns, including those of a difficult and
challenging nature. *Takes responsibility for following through and bringing outstanding issues to closure.
*Research customer information by effectively using the “Essentials” on-line resource library and Customer Service Console in response to inquiries including, but not limited to, authorizations, payments, denials, coordination of benefits, and eligibility. Readily assess and apply information to various customer situations.
*Investigates, analyzes, and resolves outstanding issues to achieve customer satisfaction; uses a systematic approach in solving problems through analysis and evaluation of alternate solutions.
*Anticipates and quickly identifies customer needs, acts independently and manages own activities with minimal supervision and direction to meet customer needs using sound decision making.
*Maintains phone quality and performance levels while working on customer related projects.
Nations Health
13621 NW 12th Street #100
Sunrise, FL 33303
Insurance Billing Specialist 5/1997 – 7/2003
*Handle billing for durable medical equipment & supplies
*Liaison with Medicare for denied claims
*Contact patients with rental and purchasing of equipment
Kemper National Services
1600 SW 80th Terrace
Sunrise, FL 33313
Network Reviewer/Customer Service Representative 5/1997 – 7/2003
*Verify Billing for Workman’s Compensation Patients
* Medical Claims Processor
*Bill Liaison
*Operations Assistant
*Resolve customer relations as necessary
*Handle inbound calls from Patients, Nurses, Insurance companies, Physicians *Label/Barcode Patient HCFA / UB92
*Data Processor
*Insure accurate payments
*Verify and update all patient and or physicians information
Reference available upon request
Contact this candidate