Angela M. Rhodes

Medical Insurance/Underwriting and Customer claims/benefits Professional

**** *. ****** *** ********* Wi. 53222

adydrb@r.postjobfree.com

414-***-****

Experienced Professional, great at resolving issues effectively. I am currently a Federal employee with the Veterans Benefits Adminstration. Offering a positive demeanor and the ability to specialize in behind the scenes roles in HealthCare Administration, Benefits and Operations, as well as Customer Service. Also over 18+ years of customer interaction, computer skills and research. Pursuing a role where hard work and dedication will be highly valued.

Authorized to work in the US for any employer

Work Experience

Rating Veterans Service Representative

Veterans Service Center- Milwaukee VA Regional Office (330)

February 2023 to present

•Determine service- connection. percentage of disability, permanent and total disability.

•Determine entitlement of compemsation, insurance,pension and burial.

•Communicates and interacts with Veterans and their representatives/advocates to facilitate timely, proper decisions.

•Works independently as a decision maker on claims, and evidence gathering for rating decisions.

•Review and analyze complex medical information, diagnostic tests, office notes and operative reports.

•Interpret statute and develop Federal regulations, policy statements, and other program guidance.

Underwriting Specialist

National General Business Solutions now an Allstate Company - Milwaukee, WI

July 2019 to Febuary 2023

•Evaluate insurance applications and determine coverage amounts and premiums.

•Analyze information stated on insurance applications.

•Determine the risk involved in insuring a client.

•Also collecting financial and statistical information for the insurance underwriter to use to determine if insurance can be provided to an individual or organization.

•Timely and accurate preparation of group documents.

•Timely and accurate preparation of rate output that requires inputting data into our rate models.

•Participates with account executives/underwriters in the renewal and new business activities that support marketing and underwriting decisions that are consistent with business unit growth and retention goals

•Partners with account executives/underwriters to establish support needs for new and renewal policies, identify/gather relevant account information to quote and/or bind the policy; create exhibits

•Manages account documentation, proposals, agreement letters, reinsurance contracts, collateral agreements, policy change, endorsements, and cancellations

•Provides administrative support and other related services as needed, input account information into system

Claims Analyst

Froedtert Health (Exceedent TPA)- Menomonee Falls, WI

November 2017 to February 2019

•Primary contact for any medical claims inquires and follow-up research on any research needed to

•get the claims repriced, processed or adjusted as needed.

•Analyze and process medical claims submitted by the doctors and medical facilities.

•Studying medical documentation; assembling additional information as required from outside

•sources, including patient, physician, employer, hospital, and other insurance companies; initiating or

•conducting investigation of questionable claims.

•Documents medical claims actions by completing forms, reports, logs, and records.

•Resolves medical claims by approving or denying documentation; calculating benefit due; initiating

•payment or composing denial letter.

•Ensures legal compliance by following company policies, procedures, guidelines, as well as state and

•federal insurance regulations.

•Maintains quality customer services by following customer service practices; responding to internal

•and external customer inquiries, as well as collection agencies if needed.

•Provides eligibility, effective and termination dates for medical plans provided by the employer, along

•with accumulators for deductibles.

•Proficient with billing software.

•Prepares reports by collecting, analyzing, and summarizing information.

•Handle and Triage all Pre- Authorization/Clinical calls as needed during a 5-month period when there was no Clinical Team available.

• Verifying if the services do need prior authorization, as well as completing form and requesting medical records

•Handles special projects as assigned, while keeping claims information confidential.

•Applying reconsideration, reviews and/or appeals procedures when necessary.

Operations Specialist

Equips - Brookfield, WI

May 2017 to November 2017

•Assist in supporting the management of the operations and service departments

•Work with other internal teams such as account management, accounting, underwriting, vendor

•management and sales to resolve issues

•Work closely with our customers and service providers to develop solutions

•Maintain a connection with our customers by providing service updates to ensure that their needs are

•being met

•De-escalate situations with customers and service providers to optimize our service to our customers

•Document open service requests with notes in the service portal to ensure an accurate history is

•captured

•Analyze service invoices and accurately enter the invoice data into the claims database

•Review coverage and provide coverage determinations

•Advise customers of potential coverage issues

•Effectively manage incoming calls from customers and service providers

•Dispatch service providers in a timely manner when a service request is received

•Utilize various software systems such as service request portals, claim/invoice systems, and inventory

•Performs other duties as assigned

Claims Analyst

Independent Care Health Plan - Milwaukee, WI

November 2008 to April 2017

•I was hired at iCare as a Provider Relations Coordinator, in November of 2008 and promoted in

•September of 2009 to the position of Claims Analyst.

•Examine claims investigated by insurance adjusters, further investigating questionable claims to determine whether to authorize payments.

•Coordinate exchange of provider information with appropriate iCare vendors. Claims, Pharmacy,

•Subrogation and Cost Saving)

•Assist the Medical Director with Medical Records and providing details to various providers in regards to Authorization request.

•Respond in a timely fashion to provider questions and issues regarding

•claims payment, in the form of reconsiderations, formal appeals and member bills.

•Interface with iCare/TriZetto personnel to establish and document claims processing, pricing and network

•policies and procedures.

•Provide prompt, courteous and excellent service to internal and external

•customers at all times.

•Research and examine problem with a claim to determine the cause of the claim's

•problem status.

•Escalate trends and educational opportunities to the appropriate contacts. Handle

•complicated or unusual claims and resolves provider issues.

•Along with conducting audits and handling special projects.

•Exercise proper judgment on questionable claims (i.e. timely filing and high dollar

•exceptions).

•Resolve/handle provider appeals according to iCare policy/procedures.

•Provide input and make recommendations for solutions to departmental and interdepartmental problems.

•Understand the enrollment, benefit and authorization process as it relates to claims

•Verify and uphold guideline of Centers for Medicare and Medicaid, Forward Health and other regulating agencies, in regards to claim submission

•Processing timely filing of ICD-9 and CPT codes/ UB-04 and HCFA forms Perform

•secondary audits on claims, reporting fraud and inaccurate claims to senior management.

Sr. Customer Care Rep. III

WellPoint, Inc. - West Allis, WI

June 2007 to March 2008

•Use computers for various applications, such as database management or word processing.

•Answer telephones and give information to callers, take messages, or transfer calls to appropriate individuals.

•Set up and manage paper or electronic filing systems, recording information, updating paperwork,

•or maintaining documents, such as attendance records, correspondence, or other material.

•Create, maintain, and enter information into databases.

•Operate office equipment, such as fax machines, copiers, or phone systems and arrange for repairs when equipment malfunctions.

•Greet visitors or callers and handle their inquiries or direct them to the appropriate persons according to their needs.

•Locate and attach appropriate files to incoming correspondence requiring replies.

•Make copies of correspondence or other printed material. Provide services to customers, such as order placement

•or account information.

•Conduct searches to find needed information, using such sources as the

•Internet.

•Inbound high-volume call center, verifying and updating coverage for providers and members.

•Providing to the provider the most current information on Medicare and Medicaid changes to codes

•and/or billing.

•Research and follow-up on inquiries in a timely manner

•Verify and/or explain policy of Medicare insurance coverage Customer Service handling, inquiries, troubleshooting Medicare billing issues.

Education

Associate of Arts in Healthcare Management

Concordia University - Milwaukee, WI

Graduated- December 2015

Skills

AS/400, Data analysis, Passport, Computer literacy, problem solving ability, strong research and

analytical skills, variety of communication skills, works very well independently or in a team setting.

Very knowledgeable of medical codes and billing practices, TPA, Medicaid, Medicare, Family Care Partnership and Badger Care Coverage.

MS Windows, Lotus Notes, AS/400, Passport System, TruCare Data analysis (10+ years), Outlook,

TriZetto, Qiclink and QNXT health claims processing/payment system. Claims review

Contact this candidate