Customer Service Quality Assurance

Aunqueta E. Wise

**** ******* ****** *** ******: 904-***-****

Jacksonville, FL 32217 Email: ********@*****.***

Summary

Dependable and professional Medical Claims Processor with 20 + years' experience in processing and coding claims, while ensuring all criteria are met before eligible payments go out. Ability to work with multiple clients while monitoring insurance billing changes.

Highlights

Proficient in insurance procedures

Auditing for overpayments

Claims adjustment

Funds recovery

Quality assurance

Able to work as part of a team or individually.

Professional Experience

2022-2023 Health Axis

Claims Examiner

Interpret and apply specific plan document language determine eligibility for benefits during claims adjudication.

Provide responsive and professional customer service for assigned groups other groups with Client as needed.

Processed complex claims requiring further investigation, including coordination of benefits, and resolving pended claims.

Review and compare information in computer systems and apply proper codes/documentation.

Placed outgoing calls to providers and/or pharmacies for further investigation before processing claims.

Complied with all quality control standards set by the company for the handling of claims.

2000- 2021 Florida Blue (Previously Blue Cross and Blue Shield of Florida)

Employee Service Advocate for Retail Store

Claims Adjustor and Analyst

Processed assigned claims.

Investigate claims for possible fraud.

Review and adjudicate high-risk claims.

Inspect claims for proper allocation of co-pays, co-insurance, and deductibles.

Trained to handle third party liability.

Responsible for disability, medical, and death claims processing.

Paid and processed claims within designated authority levels.

Ensured claim investigations are timely and appropriate, and that decisions are correct.

Conduct regular audits of random claims for purposes of quality assurance.

Investigate overpayments and funds requirements.

Processed policy changes on individual health policies.

Proficient with claim processing software: Convergence, Client Letter, Siebel, Enterprise Image Processing (EIP), Intranet Contract Benefits (ICB), Corporate Medical Clearance Application (CMCA), and the Diamond Platform.

Maintained knowledge of policy and procedures and insurance coverage benefits levels, eligibility systems, and verification processes.

Crossed trained to assist and handle status calls in the call center.

Handle internal and external customer’s telephone and written inquiries regarding billing and claims processing.

Demonstrated timely customer service and cross-functional coordination of account information to promote and maintain positive customer service.

Performed patient billing and collection activity as a result of patient contact via telephone.

Responsible for zeroing out inventory daily.

Handled written and phone inquiries related to claims and benefits.

Maintained strict compliance with related policies and procedures in all transactions, ensuring the protection of patient's Protected Health Information.

Competencies

Insurance claims processing

Data security procedures

Thorough claims review

Health insurance industry knowledge

Medical terms and procedure knowledge

Telephone etiquette

Maintained 100% quality score

EDUCATION

Americus High School

Americus, Georgia

High School Diploma

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