Customer Service Rep/Claims Examiner
Resume:
SUSAN WINTERS
Broken Arrow, OK 74014
**************@*****.*** • 918-***-****
QUALIFICATIONS SUMMARY
** ***** ****** ********** **********.
HMO/PPO/POS experience and solid comprehension of commercial, Medicare and Medicaid EOBs.
Knowledge of CPT, HCPCS, IDC-9 and UB 92 codes.
Solid understanding of PPO/POS/HMO provider contracts.
Good verbal, written communication and interpersonal skills.
Experience in collecting overpayments from Medical providers/Hospitals and members.
26 months Customer Service/Call Center Experience
1 year Internet Customer Contact Calls
PROFESSIONAL EXPERIENCE
09/2008 to 1/2011
Dell Inc.
Claims Examiner II
Processes medical which include Medicaid, Medicare and commercial
insurance claims.
Provider maintenance, loading contracts into claims systems to insure
proper claims payment.
Zenith Administrators – Deforest, Wisconsin
04/07/2006 to 08/27/2008
Customer Service Rep/Claims Examiner II
Provide prompt, accurate and excellent service to internal and external customers.
Utilize multiple company database programs for accessing customer information.
Send out requested materials/documentation such as: provider correspondence, check tracers, EOB’s, etc.
Educate customers on company plan benefits, Policies and Procedures i.e.: appeal process, timely filing guidelines, recoupments, etc.
De-escalate difficult phone inquiries from irate or emotionally upset customers. Determine appropriate resolution and provide or solicit appropriate help.
Review all claim types of claims requiring manual intervention and special processing.
Apply processing rules to determine allowable benefits for payment. Reviews services for appropriateness of charges and consider system edits.
Determine exclusions and denials based on contract provisions.
Respond to and resolve claim inquiries resubmitted for underpayment or secondary review.
Adjust payment based on findings and notify appropriate internal staff and external providers. Document files, as appropriate to support payment decision.
Identify dual coverage or potential third party liability claims.
Determine payment adjustment and release for adjudication.
Process all claims, eligible or ineligible, for payment accurately, conforming to quality and production standards and specifications in a timely manner.
Correspond with providers, members and inter-office departments to process and resolve claim issues.
Perform other duties and special projects as assigned.
Perot Systems, Inc. Tulsa, Oklahoma 09/1999 to 02/2006
Claims Examiner II
Make benefit determinations and calculations of type and level for benefits based on established criteria and provider contracts.
Identify authorizations and matches authorization to claims.
Understand and interprets health plan contract verbiage.
Consider claims with Coordination of Benefits issues to approve and update system insurance coverage profile.
Determine payment adjustment and release for adjudication.
Review higher complexity claims based on provider and health plan contractual agreements and claims.
Process all claims, eligible or ineligible, for payment accurately, conforming to quality, production standards and specifications in a timely manner.
Respond to Customer Contact Calls via the internet in a timely manner.
Perform other duties and special projects as Assigned.
Amcare (formerly Foundation Health) –Tulsa, Oklahoma
1996 to 1999
Claims Examiner
Make benefit determinations and calculations of type and level for benefits based on established criteria and provider contracts.
Process all claims, eligible or ineligible, for payment accurately, conforming to quality, production standards and specifications in a timely manner.
Perform other duties and special projects as assigned.
EDUCATION AND TRAINING
Paralegal 16 credit hours OKLAHOMA JUNIOR COLLEGE – Tulsa, Oklahoma
Computer Keyboarding MATC – Madison, Wisconsin
Dean Vaughn Medical Terminology Shared Medical Systems – Tulsa, OK GED Adult Education – Tulsa, Oklahoma
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