Customer Service Physical Therapy
Resume:
Nicole Ruggles
**** ********* **** *****, *******, NORTH CAROLINA 27616
PHONE: 248-***-**** Email: adzej0@r.postjobfree.com
Skills
Communication Skills • Problem Resolution • HIPPA Compliance • Financial Software • Organizational Management •Third Party Billing Procedures Medical Records • Medical Billing • ICD-10 • Insurance(medical) CPT Coding • Medical Coding • EMR System •Microsoft Office Programs
Work Experience
AmeriHealth Caritas North Carolina April 2021 - Present Medicaid Management Information Service
● Responsible for Providers and member calls regarding claims
● Inbound provider phone calls or correspondence regarding benefits, eligibility, and other provider claim issues.
● Reviews and adjudicates claims based on provider and health plan contractual agreements and claims processing guidelines.
● Reconcile audit discrepancies, correct them in the system, and make appropriate changes.
● To avoid recurrence.
● Monitor outstanding inquiries and work with management staff to resolve issues.
● Maintain thorough knowledge of claims processing systems, databases, and subsystems.
● Document files, as appropriate, to support payment decisions. Manpower Agency September 2020 - April 2021
Contracted ACA Enrollment Analyst with BCBS of NC
● Responsible for resolving customer, Congressional, and White House escalations submitted through the Center for Medicare and Medicaid Services (CMS). Research and resolve HICS cases to ensure compliance with Federal and/or State Requirements.
● Serve as a single point of contact providing real-time resolutions for incoming escalations/inquiries from CMS.
● Interpret, analyze, and respond to complex inquiries.
● Receive quality audits. Perform system updates related to membership and billing changes.
● Provide written documentation of case determination to CMS in a timely manner in accordance with regulatory mandates.
Theramatrix Physical Therapy Network, March 2016 - August 2020 Utilization Review Coordinator
● Customer Service, handling caseloads of concurrent review cases and monitoring utilization to ensure that outpatient physical therapy services are provided at the appropriate level and within the length of treatment guidelines which are diagnosis specific.
● Assists in keeping medical records as required by state and federal law, maintaining compliance with all confidentiality requirements for HIPAA. Assists in acquiring required physician orders and physical therapy treatment plans.
● Maintains physical therapy documentation relative to concurrent and retrospective review activities.
● Experienced with ICD-10 Codes, CPT codes, and claims. Provider Relations Coordinator
● Customer Service, use common sense, complex problem solving, and self-direction to communicate orally, written, or in diagram form to carry out contracted interpretation and compliances.
● Reconciles audit discrepancies and corrects in the system.
● Assist outstanding claims inquiries request from Providers and work with management staff to identify and resolve areas of non-compliance.
● Review provider requests and supporting documentation for accuracy and completeness and prepares this information to be added to the file according to policy, in a prompt, timely manner as directed per contractual guidelines.
United Business Consultants, July 2015 – February 2016 Account Manager/ Independent contractor
● Provided excellent Customer service to clients.
● Interviewed clients for new accounts.
● Trained and interviewed new hires on the process and procedures of sales.
● Managed B2B Sales
Education, Certifications, and License
Oakland Community CollegeWaterford,MI August 2007 – April 2012 Major: General Studies Associate’s Degree
Mental Health Social Work Program
Nursing Applicant.
Warren Health Academy Waterford, MI October 2012 – November 2012 Nursing Assistant -CNA Training
Certifications & License
M.O.R.C Auburn Hills, MI July 2009 – July 2014
Certified Direct Care Giver D.C.W training
Licensed Nursing Assistant
Certified Direct Care Giver
Awards/Certificates/License/Degree
● Licensed Nursing Assistant
● Certified Direct Care Giver
● National Honors Society
● National Technical Honors Society
● Partial Academic Scholarship to Oakland Community College
● Super Assistant of the Year Award
● General Studies Associates
References
Ashlee Cummings
FOM
VIP Petcare
Holly Whaley
Manager/Administration
Progressive Lifestyles
Matthew Laige
Manager
Fiesta Fajitas
Chris VanWagoner
Provider Relations Director
TheraMatrix Physical Therapy Network
Jill Helka
Provider Relations Director
Bright Star Home Care and TheraMatrix Physical Therapy Network 734-***-****
Tammy Bitterman
Human Resource
TheraMatrix Physical Therapy Network
John Crum
Utilization Review Director
TheraMatrix Physical Therapy Network
800-***-**** Ext 178
Contact this candidate