Healthcare Administration & Claims Specialist

Geneese Owens

Jackson, CA • 916-***-**** • ********@*****.*** • LinkedIn

Intake Representative II

Healthcare Administration Professional

A dependable and hard-working Intake Representative and Healthcare Administration Professional seeks to bring 6+ years of progressive experience to an industry-leading employer. Strong history of success in high-level claims processing, medical data entry, and healthcare administration support roles. Proven record of advocating for members while responding to and resolving complex benefits, products, services, network, and policy inquiries. Skilled in electronic record management, claims processing, medical data entry, healthcare administration support, provider communications, referrals and authorizations, problem solving, multi-tasking, and more. Diligent and goal-oriented, with the skills, education, and hands-on experience needed to make an immediate positive impact in any fast-paced team.

•Electronic Records Management

•Healthcare Administration Support

•ICD9/10, CPT, HCPCS, and 10-Key

•Word, Excel, PowerPoint, Outlook

•Complex Claims Processing

•Provider Communications

•Referrals and Authorizations

•Proactive Problem Solving

•Expert Medical Data Entry Skills

•CMS 1500 and UB 04 Claims Forms

•Detail-Oriented Multi-Tasking

•AA, AS, and AAS Degrees

Medical Programs: Care Radius(CR), Rescue Net, Real Time Membership System (RTMS), Employer Connection Plus (EC+), Enrollment Administration Manager (EAM), Membership Enrollment Tool (MEET), Facets, Medicare Advantage Prescription Drug (MARx), Provider Manager, Idocs, Notes.

Career Highlights

7+ years’ experience in claims processing, medical data entry, and healthcare administration support roles.

Using communication, customer service, and telephone management skills to inform clients/callers.

Coordinating with providers to verify diagnosis, addresses, phone/fax numbers, specialties, and more.

Processing active referrals, low level duplicates, ROFRs, MTF's not accepting, and other documents.

Researching claims to resolve issues in compliance with regulations, standards, and guidelines.

Answering a wide range of questions about complex referrals and authorization inquiries/transactions.

Advocating for members by responding to benefits, products, services, network, and policy inquiries.

Identifying, researching, and resolving discrepancies in provider, patient, and network information.

Using automated systems to process health plan information while meeting high quality standards.

Examining claims documents to determine accurate payment criteria based on policies and procedures.

Providing exceptional service to members/providers by building and maintaining professional relationships.

Meeting or exceeding high quality, timeline, and accuracy standards to excel in fast-paced settings.

Professional Experience

Chenega Services & Federal Solutions, LLC, Remote, CA

Referral Specialist II. 2025-2025

Processing Research & Repairs, referrals, Specialist referrals, & ROFRs. Much like working at Healthnet: Collaborating medical professionals, co-workers, team members to provide extraordinary customer service.

Healthnet Federal Services, Rancho Cordova, CA - Intake Representative II 2017 - 2025

Processing ROFRs (Right of First Refusal), referrals and low level duplicates, specialist referrals, and MTF’s not accepting. Collaborating with medical professionals, co-workers, team members to provide outstanding customer service.

Updating information to enter related authorizations/referral type requests (DME, BH, and outpatient).

Processing physician requests and medical information into management authorization systems.

Verifying diagnosis, addresses, phone/fax numbers, and specialties by coordinating with providers.

Resolving various staff questions about complex referrals and authorization inquiries/transactions.

Validating patient/provider data, including medical provider selection by specialty for healthcare service.

Redirecting patients into the provider network for care per high contractual standards

Processing claims according to business regulation, internal standards and processing guidelines.

Managing edits/deferrals, patient/provider identification, health insurance information, and related files.

Professional Experience (Continued):

Blue Shield of California, Rancho Cordova, CA - Promoted through multiple roles 2014- 2016

PDC Processor (May-September, 2016)

Researched claims to determine appropriate benefits and apply accurate physician contract pricing.

Added, changed, and terminated locations, practitioners, networks/panels, and hospital affiliations.

Verified/updated license and credentialing status, PCP information, active networks, and more.

Proactively identified, researched and resolved discrepancies in provider, patient or network information.

Thoroughly examined and interpreted all relevant documents included with claims to determine accurate payment criteria for clearing pending claims based on defined policy and procedures.

Met high employer accuracy, timeline, and customer service standards in a fast-paced setting.

Medicare Member Processor (2015-2016)

Performed intake/triage on emails/faxes/mail and updated billing, phone/fax, and email information.

Completed daily reports to manage eligibility and/or addresses for IFP membership, small and large group membership, Medicare supplement membership, and employer groups.

Worked independently to ensure ID cards/assignments were triggered and processed in timely manner.

Researched additional information to complete processing work and verify member eligibility/data.

Terminated eligibility and changed class, plans, PCP’s and demographics for members/family members.

Recommended improvements in work processes and task documentation for supervisors/management.

Used experience and caching skills to act as mentor/chair-side trainer for new team members.

Small Group Member Processor (2014 - 2015)

Managed group member accounts and activated eligibility for a variety of valued groups.

Used automated systems to process health plan data while meeting all production and quality standards.

Processed renewals, installations, billing updates, name/address changes, and benefit/rate updates.

Managed split contracts and performed QC to verify plans, update information, and ensure accurate data.

Used Facets, EC+, RTMS, EAM, MEET, MARx, & Provider Manager, and more professional software.

Proactively identified and resolved complex issues with enrollment information and member eligibility.

Performed research to verify the accuracy of data entry against sources and resolve escalated problems.

Career Note: Also held the related roles of Account Representative for Wittman Enterprises (2013 - 2014) and Veterinary Technician for the Bradshaw Veterinary Clinic (2008 - 2009).

Education

Associate of Arts, Medical Insurance Billing and Coding - Heald College, Rancho Cordova, CA (2014)

Associate of Applied Science, Medical Insurance Billing and Coding - Heald College, Rancho Cordova, CA (2014)

Associate of Science, Veterinary Technician - Cosumnes River College (2008)

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