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Professional Summary
Highly experienced Claims Analyst with over 19 years of Claims Processing/Adjusting on multiple related processing systems. I thrive in a fast-paced environment and have a proven track record for high efficiency and accuracy as well as exceeding deadlines and Service Level Agreements. I am seeking a challenging position in a healthcare environment that will utilize my experience with opportunity for advancement.
Skills
  • Advanced computer skills
  • Medical Terminology
  • CPT, ICD-9/10 (conversions)
  • Facility & Professional Claims
  • Customer service-oriented
  • Processing Software includes: Facets, Citrix MPS, Blue Chip, Sharepoint, Macess, Qcare, Rapid Resource, MS Office Products (Excel, Word), Lotus 123
  • Adjustments and payment recoveries
  • Quality auditing 
Work History
Medical Claims Analyst, 10/2012 to 06/2017
NTT DATA Services formerly Dell Financial Services Remote Contractor
  • Institutional/Professional Medical Commercial and Medicare claims processing/adjustments on Xcelys system
  • Examined billing for accuracy, completeness, specificity and appropriateness according to services rendered and verified authorizations for procedures according to client guidelines
  • Met and exceeded production and claims audit service level agreements according to client contract
  • Reviewed member out-of-pocket accumulations to determine accurate benefit application
  • Discrepancies in member cost share adjusted to apply correct amounts
  • Updated member files to accurately reflect changes in benefits or out of pocket accumulations
  • Performed quality control of the data entry system to verify that claims, payments and member liabilities were posted correctly
Medicare Claims Analyst, 09/2012 to 10/2012
The Jacobson Group-Excellus BCBS Remote Contractor
  • Work at Home position processing Medicare claims on Facets system
  • Followed IT Blue Card processing requirements
  • Maintain HIPAA/PHI Compliance for member files in database
  • ​Adhered to state and local mandates for clean claims submissions, CMS guidelines, with strong knowledge in Medicare Advantage products
Medicaid Claims Analyst, 04/2012 to 05/2012
The Jacobson Group-Monroe Plan Remote Contractor
  • Analyzed and adjudicated Facility and Professional claims on Facets Claims System.
  • Researched member Medicaid eligibility and applied benefits and plan information to claims processing
  • Processed 80-100 Medicaid claims to include: Facility, Professional, DME, and Home Health
Medical Claims Analyst, 02/2007 to 03/2012
Universal American Houston, TX
  • Processed, professional claims from provider to ensure claims validity accuracy and timely payment according to terms and conditions of policies
  • Analyzed and processed medical claims in accordance with contract that are Specific to each IPA and/or provider
  • Researched and adjusted customer grievances and appeals, increasing customer satisfaction
  • Reported claims activity to appropriate entities -Adjudicated and encompassed all aspects of the claim until claims are completed
Medical Claims Analyst, 03/2000 to 02/2007
Blue Cross Blue Shield of Texas Houston, TX
  • Administered claims for multiple commercial groups for members using HMO, PPO and POS services
  • Processed Payment of claims following plan guidelines
  • Researched authorizations when required for medical procedures
  • Determined benefits and member responsibilities and reviewed for accuracy
  • Assisted members with in-bound calls with claims payment questions
Medical Claims Analyst, 03/1997 to 03/2000
Prudential Healthcare Houston, TX
  • Accurately and efficiently processed Commercial HMO, PPO and POS claims.
  • Verified Medicare and Medicaid member status and processed claims accordingly
  • Followed up on claims to assure compliance with policies and timely filing guidelines
  • Exceeding processing deadlines to avoid payment penalties for Client
  • Handled Provider inquiries by phone and correspondence regarding claims status, disputes or other payment issues
  • Resolved member/provider issues at first level, escalating only when necessary
Insurance Specialist, 04/1994 to 03/1997
American Medical Response Ambulance Houston, TX
  • Processed extensive documentation to verify Workers\' Compensation coverage and eligibility
  • Processed all contract billing arrangement and facilities
  • Applied working knowledge of Medicare, Medicaid guidelines and coordination of benefit procedures
  • Performed invoicing and applied payments to Patient Accounts, reviewed denied claims for accuracy
  • Processed aging reports and rebills
  • Answered in-bound member and provider inquiries regarding claims status and payment issues
Education
High School Diploma: Jesse H. Jones Senior High School - Houston, TX

Certification: Word Processing, ITT Technical Institute - Houston, TX
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Summary
Insurance Specialist Lead . Seeking a position to develop and implement new and innovative health care improvement processes and procedures.  
Skills
  • Staffing management ability
  • Proven patience and self-discipline
  • Conflict resolution
  • Knowledge of HMOs, Medicare 
  • Strong work ethic
  • Team player with positive attitude
  • Good written communication
  • Maintains strict confidentiality
Experience
September 2011
to
Current
ARIZONA ONCOLOGY TUCSON, AZ INSURANCE SPECIALIST LEAD Demonstrated analytical and problem-solving ability by addressing barriers to receiving and validating accurate patient billing information. Strictly followed all federal and state guidelines for release of information. Acted as a liaison between the business department, billers and third party payers in resolving billing and reimbursement accuracy. Posted charges, payments and adjustments. Applied payments, adjustments and denials into medical manager system. Promptly responded to general inquiries from members, staff, and clients via mail, e-mail and fax.
October 2010
to
September 2011
ARIZONA ONCOLOGY TUCSON, AZ REVENUE CYCLE SUPERVISOR Conducted or approved the performance evaluations for Reviewed and approved time cards for processing by payroll department. Planned, organized, supervised and provided assignments for , office staff. Managed an average of 9 employees each shift. Corresponded with operations staff to ensure key revenue goals were met.
August 2005
to
October 2010
ARIZONA ONCOLOGY TUCSON, AZ INSURANCE SPECIALIST/CREDITS Verified details of transactions, including funds received and total account balances. Calculated figures such as discounts, percentage allocations and credits. Rectified escalated accounts payable issues from employees and vendors. Researched and resolved billing and invoice problems.
September 2000
to
May 2005
CARONDELET MEDICAL GROUP TUCSON, AZ PATIENT INQUIRY COLLECTIONS LEAD/SUPERVISOR Guaranteed positive customer experiences and resolved all customer complaints. Promptly responded to general inquiries from members, staff, and clients via mail, e-mail and fax.
Education and Training
1986
NORTHWEST SCHOOL FOR AIRLINE AND TRAVEL Phoenix, AZ, USA CERTIFICATE: TRAVEL
1981
PALO VERDE HIGH SCHOOL Tucson, AZ, USA
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Professional Summary
Licensed insurance professional with extensive experience in sales, prospecting and lead generation. Seeks a position offering new challenges and opportunities for career growth and advancement.
Skills
  • Strong interpersonal skills
  • People-oriented
  • Property insurance
  • Life and health insurance products
  • Strong client relations
  • Quick learner
  • Creative problem solver
  • MS Windows proficient
  • Self-motivated
  • Highly competitive
Work History
Insurance Specialist, 11/2015 to 11/2017
Natalie Barry - State Farm Insurance Agent Houston, TX
  • Calculated quotes and educated potential clients on insurance options.
  • Collected all premiums on or before effective date of coverage.
  • Followed up with customers on unresolved issues.
  • Met with prospective customers and business owners in their homes, businesses and other settings.
  • Evaluated leads obtained through direct referrals, lead databases and cold calling.
  • Modeled exceptional customer service skills and appropriate diagnostic sales techniques.
  • Contributed ideas and offered constructive feedback at weekly sales and training meetings.
  • Met existing customers to review current services and expand sales opportunities.
  • Maintained knowledge of current sales and promotions, policies regarding payment and exchanges and security practices.
Lead Sales Associate, 09/2014 to 09/2015
Academy Sports + Outdoors Sugar Land, TX
  • Recommended merchandise to customers based on their needs and preferences.
  • Maintained knowledge of current sales and promotions, policies regarding payment and exchanges and security practices.
  • Greeted customers in a timely fashion while quickly determining their needs.
  • Responded to customer questions and requests in a prompt and efficient manner.
  • Contacted other store locations to determine merchandise availability.
  • Completed all cleaning, stocking and organizing tasks in assigned sales area.
  • Prioritized helping customers over completing other routine tasks in the store.
  • Contributed to team success by exceeding team sales goals by 10%.
  • Wrote sales slips and sales contracts.
Sales associate, 03/2011 to 09/2014
Burlington Houston, TX
  • Greeted customers in a timely fashion while quickly determining their needs.
  • Maintained knowledge of current sales and promotions, policies regarding payment and exchanges and security practices.
  • Contacted other store locations to determine merchandise availability.
  • Completed all cleaning, stocking and organizing tasks in assigned sales area.
  • Prioritized helping customers over completing other routine tasks in the store.
  • Built relationships with customers to increase likelihood of repeat business.
Education
High School Diploma: 2012
Thurgood Marshall High School - Missouri City, TX
Additional Information
  • Willing to relocate: Anywhere, Authorized to work in the US for any employer
  • CERTIFICATIONS/LICENSES , Property and Casualty License January 2018 Life and Health Insurance License February 2018
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Skills
  • Medical documentation 
  • Customer Service
  • Multitasking
  • Organized
  • Familiar with ICD-9&10 and CPT coding
  • Payment collection 
  • Technical Skills
  • Dependability 
  • Quick problem solver
  • Knowledgeable in local insurances and Prior Authorization procedures
Summary
Flexible medical receptionist who can maintain organization and handle communication in a fast paced medical office. Skilled with booking appointments and patient scheduling, registering patients and monitoring status, and performing insurance verification's, specialize in handling phone duties and monitoring communication. 
Education
High School Diploma: 2009
Mohave High School - Bullhead City, AZ
Work History
Medical Assistant/Prior Authorizations&Referrals, 10/2015 to 09/2016
Western Mt. Medical Center- PC Bullhead City, AZ
  • Working at a Primary Care Physicians office I did a little of everything from answering phones, scheduling and re-scheduling patients appointments, refilling prescriptions and sending then to the correct pharmacy, checking patients in and out of the office, and taking co-payments up front. Shortly after being there I was offered the medical assistant position. I helped room patients, checked weight and vital signs and recording accurate information on patients charts. I also gave injections to patients needing B12 and or flu shots if needed. At the same time I was responsible for getting all authorizations for referrals, diagnostic images(X-rays, echocardiograms, MRI's,MRA's, ect.) and all medications, which I am very comfortable doing. I have a lot of patience being on the phone with insurance company's and getting my work done in a timely manner.




Insurance Specialist , 10/2014 to 01/2016
Painted Desert Primary Care- PC & GYN Bullhead City, AZ
  • Getting hired as an Insurance Specialist I have to know which provider will take certain insurances or I may have to re-direct so that the patients can be treated. I also send out Prior Authorization forms to insurances to get approvals so patients can see certain specialists or get any imaging done at facilities. A few of the diagnostic images I get Prior Authorizations for are for Ultrasounds, MRI's, MRA's, Pet scans, CT's, ect. Most of the time I am needing to get approvals online on the insurance websites like Humana, United Health Care, Health Choice (Evicore) ect. I am also checking patients in and out, collecting co-payments and scheduling. As of right now I am also taking patients back into their rooms and taking their vitals as our MA recently left. Being a GYN Medical Assistant i prepare patients for examinations, conduct PAP smears and assist the Doctor with procedures such as Colposcopy and Endometrial biopsy's.





Customer Service Representative , 09/2012 to 10/2014
Farmers Insurance
  • As a CSR I would greet customers warmly and ascertain any problems or reasons for coming in, resolving customer complaints via phone, email, or mail. Used telephones to reach out to potential customers or trying to win them back and verifying account information. I would take all payments and make appointments for the agent to sit down with existing and new clients for medical and life insurance. I also cancelled policies and re-wrote new policies as ling as they had the same coverage's.

Hostess/Waitress, 04/2009 to 09/2012
Joe's Crab Shack/Bubba Gump Shrimp co. Laughlin, NV
  • Working in a fast and busy environment as a hostess I would meet and greet guests, show them the way to there seating area and introduce them to their server and any special that we were having at the time. When I turned 21 in the year of 2012 I became a waitress, I then began to take orders, serve food and beverages, and try to upsel as much as possible. I would also check back with every customer to ensure that they are enjoying their meals and take action to correct any problems if needed. At the end of every shift I would do any side work that was given to me, some were cleaning the beverage station top to bottom, re stocking the pantry with and condiments that needed to be filled, rolled silverware, and made sure our seating area was as clean as it was once we got there.