Medical Claims Customer Care
Resume:
Patricia Anderson
Cool Ridge, WV *****
*************@*****.***
Professional Summary
CPC - A certified medical biller and coder with 18 years experience. Have worked in medical claim processing. Am fluent with the ICD 9 & 10, CPT codes, HCPCS codes and the RBRVS. Very detailed oriented and can multi task. Committed to processing claims accurately and expeditiously. Work Experience
Customer Care Manager
IQVIA-MA
November 2024 to Present
Take inbound calls from patients on Humira, Skyrizi and Rinvoq to help patients pay copay amounts for these drugs and reach their Out of Pocket amount without them having to pay anything out of their pocket. Also make outbound calls to pharmacies to determine benefits including Out of Pocket and Deductibles.
Experienced in Microsoft, Excel, PRM, and OPUS.
Home Health Aide
Raleigh C-Beckley, WV
May 2001 to July 2024
Provided mobility assistance such as walking and regular exercising. Increased medication and medical terminology knowledge through research and continuing education.
Assisted disabled clients to support independence and well-being. Completed entries in log books, journals and care plans to accurately document and report patient progress.
Administered medication as directed by physician.
Coordinated daily medicine schedules and administration to help clients address symptoms and enhance quality of life.
Assisted patients with dressing, grooming and feeding needs, helping to overcome and adapt to mobility restrictions.
Documented vital statistics and coordinated with health care providers. BPO Support Contractor-Examiner
JMS Associates-Farmington, MI
September 2022 to November 2023
Processing of medical claims for payment including data entry, checking procedure and diagnosis code(s) for accuracy, verifying patient and provider information and determining if procedure is allowed or if it needs authorization.
Medical Claims Examiner III
Health Smart Benefit Solutions-Charleston, WV
May 2001 to August 2019
Followed up on potentially fraudulent claims initiated by claims representatives.
Managed large volume of medical claims on daily basis. Identified insurance coverage limitations with thorough examinations of claims documentation and related records.
Reviewed and analyzed suspicious and potentially fraudulent insurance claims.
Reviewed provider coding information to report services and verify correctness.
Paid or denied medical claims based upon established claims processing criteria.
Evaluated accuracy and quality of data entered into agency management system.
Used administrative guidelines as resource or to answer questions when processing medical claims. Maintained knowledge of benefits claim processing, claims principles, medical terminology and procedures and HIPAA regulations. Read over insurance policies to ascertain levels of coverage and determine whether claims would receive approvals or denials. Documented information gathered in field and uploaded data to company database for efficient processing using AS400.
Examined claims forms and other records to determine insurance coverage.
Education
Bachelor's degree in Interdisciplinary Studies
Glenville State College - Glenville, WV
August 1986 to May 1990
Skills
• Followed up on potentially fraudulent claims initiated by claims representatives. Managed large volume of medical claims on daily basis. Identified insurance coverage limitations with thorough examinations of claims documentation and related records. Reviewed and analyzed suspicious and potentially fraudulent insurance claims. Reviewed provider coding information to report services and verify correctness. Paid or denied medical claims based upon established claims processing criteria. Evaluated accuracy and quality of data entered into agency management system. Used administrative guidelines as resource or to answer questions when processing medical claims. Maintained knowledge of benefits claim processing, claims principles, medical terminology and procedures and HIPAA regulations. Read over insurance policies to ascertain levels of coverage and determine whether claims would receive approvals or denials. Documented information gathered in field and uploaded data to company database for efficient processing using AS400. Examined claims forms and other records to determine insurance coverage. (10+ years)
• Data collection
• Medical coding
• ICD coding
• EMR systems
• Windows
• Analysis skills
• Quality assurance
• HIPAA
• Medical records
• Physiology knowledge
• ICD-10
• Medical terminology
• ICD-9
• Documentation review
• Research
• Statistics
Certifications and Licenses
Medical Billing Certification
Present
From Penn Foster
CPC-A
February 2021 to February 2024
Certification with AAPC. Actively working on having the apprentice designation removed
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