Quality Assurance Analyst/Telephone Representative

Carol F. Butler

**** *. ******* *********

Unit #14

Orlando, FL 32822

407-***-**** (Home)

Qualifications:

Previous work history as telephone representative and customer service with a health insurance company. Work History

Previous Employer: FROM: January 2017 TO: August 2020 NTT DATA

(Working on the Harvard Pilgrim Account) For Employment Verification: 800-***-**** 1600 Crown Colony Drive Company Code 10461

Quincy, MA 02169

POSITION: QUALITY TRANSACTION ANALYST

Duties Included: Identified root cause issues recommending solutions, maintains consistency and accuracy of team processes while auditing co-workers, supports automation and process improvement initiatives, performs root cause analysis on issues identified, reviews multiple contracts verifying payment accuracy, supports team in meeting 100% of all contract obligations and SLA’s, identifies overpayments from audit analysis, supports documentation and training in operational improvements and resolution of processing issues, controls release of confidential information to remain HIPPA compliant, attends meetings that pertain to auditing department. Previous Employer: FROM: July 1999 TO: January 2017 HARVARD PILGRIM HEALTHCARE For Employment Verification: 800-***-**** 1600 Crown Colony Drive Company Code 10461

Quincy, MA 02169

POSITION: QUALITY ASSURANCE ANALYST:

Duties Included: Review data entry from numerous co-workers to identify any errors maintaining consistency and accuracy of team processes, review and analyze potential issues to determine solutions, attends meetings on various processes, analyze root cause issues, reviews account/service history to identify trends, co-developed

“on the job” training guidelines with Documentation & Training, keeps current with knowledge of claims adjudication and processing guidelines, supports training and documentation with operational improvements, reviews facility, contracts, verifies accuracy in payment. Previous Employer:

HARVARD PILGRIM HEALTHCARE FROM: June 1995 TO: July 1999 1600 Crown Colony Drive For Employment Verification: 800-***-**** Quincy, MA 02169

POSITION: TELEPHONE REPRESENTATIVE

Duties Included: Review member’s history for claim status/updates from provider office, review member benefits, identify annual benefit limits and if they had been met, assess member deductible and out of pocket maximum to identify if they had been met, track necessary call backs for further resolution and documentation needed, track amount of calls taken per day and any follow-up resolution needed, identify and document any issues found, maintain targeted productivity levels, adjudicates claim if needed. Previous Employer:

HARVARD PILGRIM HEALTHCARE FROM: December 1991 TO: June 1995 1600 Crown Colony Drive For Employment Verification: 800-***-**** Quincy, MA 02169

POSITION: CLAIMS MEDICAL EXAMINER/DATA ENTRY:

Duties Included: Enters information from medical claim submission into the data entry system for processing, reviews any documentation for manual processes of claim, follows guidelines required for each service type, asks questions as needed.

EDUCATION:

HIGH SCHOOL DIPLOMA – 1978 West Roxbury High School Business Courses VFW Parkway W. Roxbury, MA Please note: Certification of medical coding was not required in Massachusetts, however I am willing to take courses if necessary.

SKILLS:

Typing (approx. 60 wpm)

Interprets Contracts

10-key Numeric Entry

Microsoft Office/Excek

Medical Terminology

Various Database

Outlook

Facility/Medical Coding

HCPC/CPT/ICD9/ADA Coding

Root Cause Analysis

REFERENCES:

Teresa Padrick 321-***-****

Contact this candidate