Customer Service Follow Up

Debra Phorne (TEXAS)

Phone: 972-***-****

Email: *******@*******.***

Employment History

**/ **** ** ******* ******* RETRIEVAL SUPPORT

Insight, - ISG, IMO Financial - Remote MA

Handle calls out/in bound, to obtain Medical, Billing and Radiology film/ other records regarding cases/ lawsuits.

Follow up once Subpoena has been sent certified or served to Hospitals/Insurance/ other businesses involved in cases

Heavy data input and giving a detail on responses/actions taken.

Follow up on and assist with any requests to move cases forward.

Handle and find missing information.

Experience in ROI - Release of information request

Experience in reading and understanding Subpoenas, Medical Records, Workers Comp, Auto Liability cases and General Liability cases.

04/2023 - 07/2023 Claims Operations Assistant/ Adjuster Assistant, Insurance Claims and Policy

Processing Clerks

ALTA IT STAFFING - Temp Remote, Rockville, MD

Tasked with constructing a claim from initial loss reports received via email, app, fax, or phone.

Retrieve and integrate the appropriate policy into the claim file, assign the claim to the correct adjuster, and verify details while ensuring no duplicates exist.

Choose the accurate policy language for insurance and assign policies that are renewed, not bound, or expired.

Incorporate new insured locations into the policy and ensure underwriters are informed of any corrections to policy dates or adjustments to covered location addresses, especially when nearing policy expiration. Possess knowledge of the insurance industry, its products, services, and business lines…EOB’s, 837i AND 227 to work received rejected or denial claims from a payer. Call on and follow-up with payer to get a corrected claim in on time or see if claim was sent to 2ndary payer. Experienced with policy management systems in the insurance sector and collaborating with Fraud/Compliance and Legal Departments to report suspicious activities/trends through SARs.

Guarantee that all notices are dispatched in accordance with the claim type, such as RPO, MO, MO with RESERVES, and LOSS TIME with RESERVES, with documents electronically attached and correctly sent to employees or employers.

Allocate an appropriate number of follow-up days to adjusters and/or their managers to ensure claims are pursued promptly and in compliance with state regulations.

Utilize various systems, documentation, and reference materials to guide the setup, assignment, and follow-up of each claim. Systems include Guidewire, Claims Connect for imaging, Mavern for policy management, SharePoint for instructions, and the S: Drive for State Guideline directions. 07/2020 - 12/2022 Cash Management Admin Specialist- Claims Fraud, {P, Insurance Claims and Policy Processing Clerks

Dicker Temporary StaƯing Services for Brink's – Cash Management, Dallas, TX Investigated customer inquiries and Workers' Comp claims, addressing issues related to products and services for Brink's Total Loss Cash Management. Managed incidents of potential fraud at assigned bank branches, including ELAN, WSFS, CARDTRONIC, NCR, Nexus-Lexus, Salesforce, and Cisco Systems.

Handled claims by working with various insurance carriers' provider portals, such as Availity, to check for EOBs and verify insurance benefits and negotiated rates.

Performed data entry, documenting details of claims such as ATM theft, loss, or damage, as well as specific loss types occurring during the transit of money, bags, or large cash amounts up to $200K (ATM, MP, CIT, VAULT). Processed shortage claims, including money delivery shortages or deposits to and from stores and banks. Gained experience working with Fraud/Compliance-Risk/Legal departments on suspicious activities and trends, with SARs written. Constructed claims, entered all relevant lost data, summarized findings, and provided directions to resolve losses involving money, ATMs, or called for additional lost data.

Assigned claims to the appropriate Claim Administrator for full assessment and compensation decisions.

Researched and contacted clients for any missing or questionable information to resolve claim issues.

Documented files professionally, including all key actions taken, next steps, and interactions with customers, vehicle providers, and internal partners. Maintained excellent verbal and written communication skills for eƯective maintenance and collaboration with cross-functional team members and departments.

03/2020 - 07/2020 ARGO Pro, Insurance Claims and Policy Processing Clerks Argonaut Insurance, San Antonio, TX

Issue DWC notices and other notices in a timely manner. Complete phone calls and tasks assigned on behalf of the Adjuster, such as preparing and merging DWC State mandated letters for Workers' Compensation.

Preparing billing of medical claims prepare physician referrals and billings.

Know how to read EOB’s, 227, 837i files

Ensure professional, well-written correspondence and communications. Select and attach the correct policy language to insurance documents and assign policies that are renewed, not bound, or expired. Draft new locations for insureds not yet added to the policy and inform underwriters/UA.

Assistants of any corrections to policy dates or covered location addresses, especially when policies are nearing expiration to pursue renewals before cancelation dates.

Collaborate daily with UA Assistants.

Work closely with Fraud/Compliance/Risk Departments, report potential fraud issues through SAR reports, and assist the Legal Department with ongoing litigation related to policy/claim issues. Utilize policy management systems common in the insurance industry. Handle suspicious activities/trends in collaboration with Fraud/Compliance Risk/Legal departments, documenting with SAR reports. Send appointment letters to Treating/MDO medical files. Schedule interpreters for appointments, depositions, etc. Request Employer's Reports, DWC-1, Doctor's First Reports as needed. Maintain contact with clients, injured workers, attorneys, doctors, vendors, and other parties.

Prepare physician referrals and billings.

Know how to read eob’s, 227, 837i files

Collaborate with Senior Claims Examiners, Nurse Case Managers, and other Assistant Claims Examiners, MDO, Attorneys.

Send Requests for Authorization to Adjusters and Utilization Review. Collect and prepare medical records and other documents to send to the referred provider or UR Department.

Create new claim files in Image Right. Contact claimants, employers, or treating physicians for missing FNOL/initial loss information to process payments or approve services/obtain W9 forms.

Prepare payment disbursements, including Mileage reimbursement, and print maps to Image Right.

10/2019 - 02/2020 Claims Assistant, Insurance Claims and Policy Processing Clerks Amtrust Insurance Co, Dallas, TX

Handle investigative and written tasks assigned to complete on behalf of an Adjuster, such as preparing and merging DWC State-mandated letters for Workers' Comp.

Draft new locations of insureds not yet added to the policy and ensure underwriters are aware of corrections to policy dates or covered location addresses, especially when close to the policy's expiration. Possess knowledge of the insurance industry, its products, services, and lines of business.

Have experience with policy management systems used in the insurance industry.

Call for missing FNOL information or other missing details and verify the claim's information is valid to process payments, such as W9 forms. Prepare mileage reimbursement and print maps to IR with the pay code suƯix.

Preparing billing of medical claims prepare physician referrals and billings.

Know how to read EOB’s, 227, 837i files

Add a '9' to commercial and work comp claims for payments. Select the correct policy language for insurance and assign the correct policy as renewed, not bound, or expired.

Send appointment letters and forward them to Treating/MDO medical files. Schedule interpreters for appointments, depositions, etc. Request Employer's Report, DWC-1, Doctor's First Report if necessary. Contact clients, injured workers, attorneys, doctors, vendors, and other parties.

Prepare payment disbursements for mileage reimbursement and print maps to IR with the pay code.

Handle administrative tasks for work comp adjusters, covering West Coast claims including California, Arizona, Washington, Nevada, Oregon, Texas, Oklahoma, New Mexico, and Utah.

Print letter forms prepared to Image Right, find missing information for FNOL.

Systems used include Salesforce, Teams, Outlook, Citrix, and Excel. AEROTEK (TEMP) for Walgreens Alliance Rx as an Rx Insurance Benefit Verification Specialist - Pharmacy.

08/2018 - 02/2019 Insurance Benefit Verification Specialist, Insurance Claims and Policy Processing Clerks

AEROTEK, Addison, TX

Verify patient insurance coverage to ensure coverage of necessary specialty prescriptions.

Prepare and initiate prior authorizations in Cover My Meds and work with Script Med, Emdeon, and Excel-based Electronic Chart note Templates. Collaborate with various insurance carriers to verify benefits and contracted rates.

Research, investigate, and resolve complex financial transactions, including exceptions, variances, or posting errors. Possess knowledge of the insurance industry, its products, services, and business lines. En

Experience in working with Fraud/Compliance, Risk/Legal departments on suspicious activities and trends, with written Suspicious Activity Reports

(SAR).

Confirm whether claims are paid at the correct contractual rate, understand Explanation of Benefits (EOBs), and Benefit/Policy language.

Preparing billing of medical claims prepare physician referrals and billings.

Know how to read EOB’s, 227, 837i files

Conduct extensive follow-up calls for claims daily, contacting Health plans, Medical Doctor's OƯices, and patients.

11/2017 - 08/2018 Verification & Claims Refund/ Account Reconciliation, Insurance Claims and

Policy Processing Clerks

Addison Insurance Group, Addison, TX

Conduct research and review payments on claims according to the Explanation of Benefits (EOB), and calculate them against contracts for various services, including inpatient and outpatient. Manage incoming calls from patients and Baylor doctors or clinics regarding the status of claims.

Follow up with Health Plans to determine the reasons for over payments or underpayments.

Respond to patient phone calls about the status of refunds or underpayments, informing them whether a refund is due or, according to their plan contract, additional payment is required on the claim.

Preparing billing of medical claims prepare physician referrals and billings.

Know how to read EOB’s, 227, 837i files

Address denials and liaise with insurance companies concerning underpayment and over payments systems: EPIC, Citrix, Cirrus. Fraud Reporting Analyst / Claims Account Reconciliation. Conduct Claims Handling Reviews to analyze trends, issues, or potential fraud related to claims, outcomes, and reimbursement. Collaborate with various insurance carriers to verify benefits and ensure compliance with contracted negotiated rates.

Review payments on claims as per the EOB and assess them against contracts for accuracy or to identify trends that may require further concern or reporting.

Perform Insurance Verifications for underpayments and over payments. Systems: EPIC, Citrix, Cirrus, covering Commercial, Medicare, and Medicaid plans.

Ensure claims are paid at the correct rate and provide detailed explanations for any variances and overpayment information. Understand and interpret billing for Inpatient and Outpatient services, Hospital & OƯice billing, UB, EOB, contracts per procedures, fee schedules, case rates, or DRG groupers.

Utilize systems such as Epic, Med Asset (EOB system), and Citrix. Additionally, work with various eligibility systems for carriers, such as Availity.

01/2017 - 11/2017 Fraud reporting Analyst / Claims Account Reconciliation, Insurance Claims and

Policy Processing Clerks

US ANESTHESIA PARTNERS, Dallas, TX

Analyzed trends, issues, and potential fraud in claims, outcomes, and reimbursements.

Worked with multiple insurance carriers to verify benefits and ensure compliance with contracted rates.

Reviewed claim payments against EOBs and contracts to ensure accuracy and identify concerning trends.

Conducted insurance verification for underpayments and over payments using systems like EPIC, Citrix, and Cirrus, covering Commercial, Medicare, and Medicaid. Preparing billing of medical claims prepare physician referrals and billings.

Know how to read EOB’s, 227, 837i files

Verified that claims were paid at the correct rate, providing detailed explanations for any variances and over payment information. Understood billing processes for inpatient and outpatient services, hospitals, and oƯices, including UB, EOB, contract procedures, fee schedules, case rates, and DRG groupers.

Utilized systems such as Epic, Med Asset, and Citrix, and worked with various carrier eligibility systems like Availity. Education History

05/1985 General High School Curriculum

High School Diploma

David W Carter, Dallas, TX

Occupational Licenses, Certificates and Training

02/2021 Management & leadership Skills: Planning & Execution Indeed

10/2020 Work Style

Indeed

10/2020 Management & Leadership Skills: Impact &

Influence Indeed

07/2019 Medical Billing

Indeed

07/2019 Basic Spreadsheets with Microsoft Excel

Indeed

Detailed References

References Available on Request

Contact this candidate