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Medical Insurance Specialist

Location:
West Lafayette, IN, 47906
Salary:
15.00
Posted:
August 23, 2012

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Resume:

Koni Cramblit

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

West Lafayette, IN 47906

Cell: 563-***-****

Email: vdid9x@r.postjobfree.com

I am a dedicated, ambitious, and professional person. I have a long history and diversities in the health care and insurance business. I am extremely adaptable to environmental changes.

Work Experience

Medical Billing Specialist

Indiana Neurology Specialty Care-Lafayette, IN

Sept. 2011 to June 2012

• Identifying appropriate ICD 9 codes for the diagnosis that the doctor translated on the charge slip

• Transferring patient information, services rendered with appropriate CPT codes, ICD9 codes and correct insurance information into software system that transfers claim/s to insurance companies (Medicaid/Medicare/Tricare, etc.) electronically or generating claim onto HCFA form for manual mailing

• Posting patient payments

• Posting insurance company payments, applying correct co-pays, deductible, co-insurance, payment adjustments and contractual write-off amounts towards the patients account from EOBs (Explanation of Benefits) & ERA’s (Electronic Admittance Advices)

• Reviewing EOBs & ERA’s received that have been rejected and identifying the denial message and decipher the message, reconcile it with the original claim, make required corrections and resubmit the claim for reconsideration of payment

• Reviewing denied claims that may require filing an appeal; which may entail further investigation by contacting the insurance company to get further information to inquire if the claim can be reconsidered by submitting appropriate additional medical documentation, proof of timely filing, pre-authorization evidence for further review and successfully overturn the original decision.

• Contacting patients in regard to past due accounts for collection of payment

• Sending pre-collection notices to patients prior to forwarding to collections department

• Knowledgeable with HIPPA regulations

Senior Provider Service Representative

UNITED HEALTH CARE - Moline, IL

April 2007 to July 2011

• Provide verification of coverage & coordination of benefit questions to providers

• Quote subscriber's benefits to providers

• Determine if Pre-authorization is required on specific medical procedures, inpatient admission, and mental/substance abuse

• Assist providers with claim information on paid, processed & pending claims

• Provide accurate fee schedule information to providers

• Assist providers with resolution of complex claims

• Work with claims adjustment unit to rectify claim problems that were processed inaccurately or needed additional information for processing

• Assist providers on Appeal procedures

• Work with Provider Relations to resolve ongoing problems/issues for providers

• Work with Benefit Contract Review on fee schedule and contract issues

• Work with Manager, Supervisor and colleagues on new ideas to provide better customer service, develop overall consistency and proficiency within the department

Senior Group Life, Medical & Disability Underwriter

SENTRY INSURANCE - Stevens Point, WI

January 2002 to April 2007

• Review Statement of Health applications and claim reports containing medical

information for determining acceptance or declination of Life/Medical/Short-Term

Disability/Long-Term Disability Insurance coverage

• Prepare and analyze demographic information by calculating rates and premium charges

using designated formulas for accessing risk to generate accurate and appropriate

pricing patterns according Underwriting policies and state regulations for small groups

and renewals

• Work directly with the Underwriting Manager, actuarial, compliance, and reinsurance for

potential new employer group accounts and existing group account renewals

• Assist Sales Representatives with benefit/plan design, underwriting requirements,

completion of required state forms/applications for finalizing new business,

communicate/negotiate quote rates and renewal rates

• Report appropriate diagnosis codes to MIB

• Recommend fresh new ideas and listen to others in the department to strive for

consistency and proficiency of effective streamline processing

Senior Group Life & Medical Underwriter

SENTRY INSURANCE - Stevens Point, WI

August 2000 to December 2001

• Review Statement of Health applications and assesses risk of insuring prospective new accounts

• Review medical claim reports by identifying medical diagnosis (ICD9 & CPT codes) in determining medical modifier of individuals medical diagnosis

• Blend past experience with fore-casted claims using medical modifier to weigh

creditability of past experience in predicting the future experience

• Analyze above factors to establish rates within state regulatory guidelines

• Assist Sales Representatives with benefit plan design, completion of required state forms, and

Underwriting requirements

Life & Medical Underwriter

JOHN DEERE INSURANCE - Moline, IL

September 1999 to July 2000

• Reviewed medical claim detail reports which contain ICD9 and CPT codes to identify

medical diagnosis and procedure in determining a medical modifier for renewing group

accounts within requirements of the Underwriting policies and state regulatory guidelines

• Determined if additional information was necessary to underwrite account and

performed appropriate follow through without oversight

• Guided Sales Representatives in areas such as benefit selection and underwriting

requirements

Benefit Coordinator

JOHN DEERE INSURANCE - Moline, IL

February 1998 to August 1999

• Assisted members, Group accounts, and Sales Representatives regarding benefits,

billing issues and claim related questions

• Completion of enrollment application, changes, and cancellations for group members and

Group accounts

• Initiated COBRA and state continuation for eligible employees

• Assisted Sales Representatives with plan benefit design to satisfy Group Account’s

needs, completion of required state forms and Underwriting requirements

Skills

• Maintains accurate documentation; give meticulous attention to detail

• Displays the ability to learn rapidly and adapt quickly to changing situations

• effectively develops organizational structures and systems

• Familiar with computer applications including Word and Excel

• Team Player

Education

• American Institute of Business - Des Moines, IA

• Medical Coding Class – Milwaukee, WI

References:

Jasmine Lee, Office Manager MaryAnn Struble, Enrollment Supervisor Indiana Neurology Specialty Care United Health Care, Moline, IL

Phone No.: 317-***-**** Phone No.: 309-***-****



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