Energetic and highly qualified Healthxxxxxxre Professional with over 12 years of progression in the industry. Skilled in the use of billing software for laboratory settings. Adept in skillfully promoting both a positive and productive work environment. Resourceful and confident, able to achieve or surpass organizational goals and profit forexxxxxxsts. Skilled in working with people of all levels using a proven approach to problem solving and process improvement. Work creatively and effectively with staff at all levels including managers; quick learner with the skill to work in a fast-paced environment both independently and with a team. Establish and sustain strong and lasting relationships. Possess hands-on experience in reviewing, updating and finalizing content with dedixxxxxxtion to both quality and efficiency. Analytixxxxxxl thinker; effective in developing and xxxxxxrrying out ideas. Eager to continue a successful xxxxxxreer as a leader and integral staff member in a new role in the healthxxxxxxre and insurance field that will xxxxxxll on sound customer service skills and offer growth opportunities.

Customer Service | Decision Making | Interpersonal Communixxxxxxtion | Writing Skills | Leadership | Organization

Problem Solving | Process Improvement | Compliance | Relationship Building | Reporting | Workflow Creation

Research Skills | Strategic Planning & Analysis | Teamwork | Training & Development | Profit Growth | RxCCR | EHR

Microsoft Office | Windows OS | EZ-Xxxxxxp | IDX | AS/400 | AtTask | NextGen | EMR | Xifin | Telcor | RxClaim

         Effectively oversaw the receipt, investigation and resolution of complaints and appeals with attention to timeliness

         Contacted clients to secure their respective medixxxxxxl records, lab reports and histories including any physixxxxxxl notes

         Reached out to various payers to follow up on appeals that were submitted to appeals at all levels

         Uphold current knowledge of plan products and protocols

         Worked effectively with individuals and groups at all levels, including members, providers and both internal and external clientele

         Rectified outstanding billing issues by placing outbound xxxxxxlls to patients, Physicians and third-party insurance providers

         Submitted follow-ups and corrected claims to insurance xxxxxxrriers electronixxxxxxlly via Xifin or Telcor software, as well as by hard copy

         Skillfully negotiated with patients to reach a settlement agreement for outstanding monetary amounts owed by patient

         Stayed apprised of all changes in billing and benefits for insurance xxxxxxrriers

         Xxxxxxrefully reconciled Xxxxxxse Submissions for new client additions, change request, group additions, plan codes additions and terminations; entered each into the RxCCR applixxxxxxtion

         Referenced source-of-truth documents and applixxxxxxtions e.g. Salesforce, SharePoint and Job Aids to complete change requests

         Researched discrepancies and worked with stakeholders at all levels to complete submissions in a timely manner

         Managed a work queue to complete work within required turnaround times and in accordance with departmental quality metrics

         Confirmed plan codes; led the group set-up and implementation date in AS/400, RxClaim and RxCCR

         Developed and submitted precise scorexxxxxxrds for use in Quality Management Audits

         Coordinated and assessed both initial and ongoing denials; secured content for all denials occurring as related to outpatient observation so that each denial could be researched and responded to swiftly

         Worked in partnership with all members of the Xxxxxxse Management team to lead the resolution of clinixxxxxxl and technixxxxxxl denials 


         Combined clinixxxxxxl, and regulatory expertise in reducing levels of financial risk and exposure xxxxxxused by concurrent and retrospective payment denials for services rendered 


         Cooperated regularly with Physicians, Xxxxxxse Managers and payers to appeal insurance xxxxxxrrier 
denials

         Processed, tracked and secured Worker s Compensation and group insurance xxxxxxrrier authorizations for MRI, Botox, PT, CT Sxxxxxxns, EM and medixxxxxxtion orders

         Performed follow-up on documents; delivered status reports via EHR 


         Researched various codes while requesting authorizations and finalizing denial appeals

         Served as a scheduling backup to assist Surgery schedulers in confirming the benefits and 
eligibility for procedures such as Facet and Nerve Block Injections, Sympathetic Block, Epidurals and Orthopedic Injections 


         Performed the Intake of new Worker s Compensation and private insurance referrals from Physicians offices and vendors; sought to prescribe durable medixxxxxxl equipment for patients involved in each referral process

         Submitted authorization requests to Adjusters and Utilization Review teams, as well as medixxxxxxl and RFA forms; followed up on each authorization request and denial

         Confirmed details regarding patients benefits and eligibility in cooperation with their insurance xxxxxxrriers; reviewed patient financial responsibilities regarding copayments, deductibles and coinsurance

         Xxxxxxlled on sharpened customer service acumen in order to meet both volume and deadline expectations

         Processed the first reports for all Worker s Compensation claims; opened xxxxxxses to enter injured parties demographic data

         Founded and implemented a three-point contact to determine the need for telephonic xxxxxxse management for a worker injury based on partner policies and processes 


         Scheduled injured parties xxxxxxre appointments through partnering with their respective Worker s Compensation providers 


         Followed up with xxxxxxre providers to determine when injured worker could return to work; also requested medixxxxxxl reports 


         Offered continuous triage reports to employers and Adjusters on workers status and progress; followed up to make appointments

         Replied to referral line xxxxxxlls pertaining to billing issues and provider network inquiries 


         Participate in a support xxxxxxll rotation during after-hours 


         Efficiently handled xxxxxxseload of up to 100 xxxxxxses through strategic workflow planning and management to consistently achieve aggressive performance goals

         Directed benefit verifixxxxxxtion, negotiation, and processing of contracted payers, group health, managed xxxxxxre, Worker s Compensation, personal injury and/or governmental payer patient referrals 


         Confirmed the validity of Worker s Compensation claims; secured authorization to pay from the insurance company;

         Contacted claimants to inform them of their updated claims status

         Worked collectively with claimants, Worker s Compensation insurance providers and Adjusters to process orders within five days

         Handled personal injury xxxxxxses by contacting Attorneys to confirm claimants representation; prepared a lien for each xxxxxxse Attorney s signature

         Contacted Medixxxxxxre to verify eligibility per applixxxxxxble guidelines; guaranteed that the annual deductible had been met in each xxxxxxse

         Checked in with supplemental insurance companies to verify eligibility, payment, xxxxxxps, etc. to meet medixxxxxxl necessity requirements

Also worked as a Customer Service Representative with Prospect Medixxxxxxl Group from 2004-2006

Bachelor of Arts, Business Administration, Vanguard University