Claims Examiner & Collections Specialist
Resume:
July **** to Present
Jessica Jackson
Fort Worth, TX 76126
469-***-**** • *************@*****.***
Objective
I am looking to be a pivotable asset in a new, exciting role that would allow me to grow as well as bring a new perspective to show the future company the essential skills I could bring to propel my new company forward . I have multiple years in customer service with knowledge in coding and medical billing. While also being detail-oriented and having management experience. As well, I believe I’m never not capable of learning and looking forward to being coached and working with an amazing team.
Work Experience
Senior Claims Examiner
QMACS- Remote position-Fort Worth, TX
Resubmitting out-of-network claims.
Submit appeals for provider and independent emergency facilities. Request negotiations and payment appeals for urgent care and ambulatory low-paying claims. Appeal no Surprise Act affected claims. Negotiate payment agreements on behalf of third parties.
Collaborate with patient advocate groups to support medical providers and secure payment for patient support.
Perform detailed reconciliations between vendor platforms, internal systems, bank reporting, and payment batches to ensure financial accuracy and completeness.
Research, analyze, troubleshoot, and resolve errors, including processing errors, promptly.
Collections Specialist
Bridgecrest-Irving, TX
Negotiated and collected outstanding debts from delinquent customers. Maintained consistent metrics.
Developed processes and standards of operations to guide collection targets. Utilized effective communication skills to establish rapport with debtors, facilitating successful payment arrangements.
Maintained accurate records of all collection activities, ensuring compliance with regulatory requirements.
Handled escalated chat customer service and managed multiple chat and cyber communications to resolve customer issues.
April 2023 to February 2024
September 2021 to March 2023
Some college
Highschool diploma
Provider Relations
CHRISTUS Health-Irving, TX
Resolved provider and facility claims disputes, explained requests for clarification on denials, and handled appeals efficiently and promptly. Previously worked remotely while managing casework for commercial providers.
Updated demographic and payment systems. Collaborated with other departments on special projects related to provider relations. Responded promptly to inquiries from both internal staff and external customers. Managed as a team lead to provide insight and knowledge to 22 agents. Assisted with escalated and complex claim requests. Reviewed payment reports and medical records to create detailed timeline breakdowns for formal complaints. Resolved appeals and rejections of claims. Created caseloads and followed up with providers and facilities. Interrupted plan details for providers.
Out of Network Specialist
MultiPlan PHCS Private HealthCare Systems-Irving, TX Mentor agents uphold high-quality performance metrics. I efficiently and promptly addressed claims disputes, requests for clarification, and appeals.
Furthermore, I calculated and disbursed compensation for medical expenses while elucidating the pricing
methodology and coding compensation.
Negotiate clearing house procedures by using blue book pricing for standard payout
Education
Marygrove College
Detroit, MI Western Hills high school
Fort Worth, TX
Skills
Claim negotiation Medical terminology Knowledge of coding and explanation of benefits UB04, CMS 1500 Denials and appeals Ambulatory appeals Provider payment services Customer service Banking Funding Escalation Federal appeals Scheduling Insurance follow-up Insurance verification Coordinator Authorization Management Escalation and Tier 3 compliance reviews Achievements
Achieved the highest quality score and recognized as the top negotiator. Received perfect call scores three times.
As a team leader, my team maintained the best productivity for four consecutive months, along with the highest average handle time (AHT) and the lowest achievement (ACH) rate.
I received the best resolve rate for federal ambulatory and emergency no- surprise underpaid claims.
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