Customer Service Benefits Specialist

KATHLEEN WILLIAMS

**** **** **** ****, ******** City, TX 77459

****************@***.*** 832-***-****

CAREER OBJECTIVE

Competent medical insurance professional experienced in claims processing, patient registration, member insurance verification and prior referral authorizations. Successful on the delivery of excellent health care services with extensive experience in prior authorization, claims administration and customer service. An effective communicator who performs well in a high production environment where I thrive as part of a team, as well as independently. Perform excellent quality, performance and crisis management skills. Ethical with a high level of professional integrity, loyalty and commitment.

PROFESSIONAL EXPERIENCE

United Healthcare (Contract) - 01/20/2024 – Present

EMR Scheduling Coordinator

Use EMR System to process faxes.

Manage clinical schedules to allow the process to function smoothly.

Update and maintain provider list.

Texas Childrens Health Plan (Contract), Houston, TX - 10/2022 to 06/30/2023

Claim Benefits Specialist/Claims Examiner

Review and adjudicate medical claims based on Texas Children Medicaid contractual agreements and claim processing.

Review basic hospital and surgery billings.

Refer to TCHP reference manuals of fee schedules, CPT, ICD-10, HCPCS, and other industry publications to support findings.

Process all DME claims per invoice and no authorization denials and appeal claims.

Identify and reportion adjudication inaccuracies that are related to system configuration, member eligibility benefits, and fee schedules.

Analyze and make decisions on claims with medical records to transfer them to utilization review.

Prepare and generate appeal letters, forms, and other information relating notices to providers appeals and untimely filing.

Identify and resolve claim rejections.

Cigna Medicare Health Plan, Houston, TX - 10/2010 to 08/2020

Senior Care Representative

Processed authorizations and referrals submitted by phone, poral and fax from providers. Navigated payer portals, obtained authorizations, and reviewed payer correspondence.

Document system according to the insurance verification guidelines to assure accurate guidelines and timely reimbursement.

Review Managed Care contracts and health plans to understand the scope of coverage for services rendered or party.

Coordinate the submission of clinical documentation from physicians to payers for authorization needs.

Navigated payer portals, while obtaining authorizations and reviewing payer correspondence.

Calculate accurate patient financial responsibility.

Responsible for accurately verifying member’s insurance benefits with insurance carriers, and third-party employers.

NYLCare Health Plans, Houston, TX - 08/1993 to 05/2000

Claims Benefits Specialist/Claims Examiner

Processed medical claims, reviewed denials, evaluated refund requested, and completed contractual adjustments if needed on the claim.

Resolve claim processing error edits and identified non-billable charges.

Providing outstanding customer service communicating payment and denial decisions in a clear and professional manner.

Escalate difficult issues up the chain of command if needed.

EDUCATION

Saint Dominic’s Roman Catholic School, St. David’s, Grenada

American Business Institute, Computerized Bookkeeping Certificate -1986 to 1988

SKILLS

EPIC, Availity, Accounting, Customer Service, SAP, Microsoft Office Suite, Next Gen, Centricity, QuickBooks, Microsoft, Telecommunications Knowledge and skills, CPT, HCPS and ICD-10.

REFERENCES

Available upon request

Contact this candidate