Senior Claims Research Representative

PERSONAL OBJECTIVE
A responsible and challenging career that will utilize my education and background, expand my knowledge, and offer opportunities for personal and professional growth. I am willing to relocate to advance in my career.

QUALIFICATIONS
Excellent Communication Skills•••••Provider Relations/Provider Services Elderly Caregiver
Set, Meet Deadlines & Goals•••••Provider Contracts/Provider Credentialing•••••Highly Organized
Detail/Efficiency Oriented•••••Medicare & Medicaid Billing••••• Customer Service
Troubleshooting/Coordination•••••Insurance Billing/Collecting •••••Data Entry/••••• Key
Staff Orientation Training•••••Lab Courier/Phlebotomist/Specimen Processor Site visits/audits
Warehouse/Production•••••Management/ Deposit/Money Management•••••
Computer knowledge includes: Microsoft Works, Word, Excel, Office, Spreadsheet, PowerPoint, etc.

EDUCATION
Watson Chapel High School Graduated May •••••, •••••
National Medical Systems Received Computer courses Certificates •••••/•••••/•••••
Humana/PCA- Received Provider Services Training course Certificate •••••/•••••/•••••
The Basic Principles for a Collaborative Workplace Certificate •••••/•••••/•••••
Giving Recognition Certificate •••••/•••••/•••••
Giving and Receiving Constructive feedback Certificate •••••/•••••/•••••
Writing to get things done Certificate •••••/•••••/•••••
Franklin Covey: Achieving Your Highest Priorities Certificate •••••/•••••/•••••
Proofamatics Certificate •••••/•••••/•••••

EMPLOYMENT
Senior Claims Research Representative, United Healthcare••••••••••/•••••/••••• to •••••/•••••/•••••
Responsible for the implementation and day to day performance of process activities related to claim research and resolution activities. These processes include the review of claims, contracts and fee schedules to identify processing, procedural, systemic and billing errors. Provide network-based health and well-being benefits and services for Providers nationwide. Managing project work plans, risk issues, status reporting, and communication through phone, fax, email and mail. Perform tracking, status reporting and assist with the ongoing development and maintenance of the network. Act as a liaison for participating practitioners in resolving questions, concerns, complaints and claim issues. Resolve provider questions and concerns regarding policy and procedure and claims payment practice. Researching, verifying information and matching claims to contracts or benefits. Managing and resolving complex escalated issues for providers. Coordinating high-profile communication, planning and resolution activities between various internal business units. Facilitating restoration of relationships with providers. Providing support during legal arbitration and similar situations.

Credentialing Specialist, Arkansas Blue Cross Blue Shield •••••/••••• •••••/•••••/•••••
Responsible for mailing out applications and contracts to the Providers. Processing of incoming provider applications and supporting documentation. Perform credentialing/recredentialing primary source verification. Conduct verification of DEA Certification,
hospital privileges, education, board certifications and malpractice insurance coverage and all malpractice claims filed against a
provider in the initial credentialing and biennial recredentialing of network physicians. Obtain references when needed. Obtain
missing file for initial credentialing and recredentialing of files. Complete follow-ups until all information have been received.
Accurately maintain credentialing/recredentialing program databases. Effectively communicate with practitioners and health care
delivery organizations to obtain necessary data. Maintain site visits and auditing records.

Customer Service Representative, NMHCRX ••••••••••/••••• Present
Answer phones and provide benefit information to members/providers, document calls, complete benefit overrides based on the plan design, research problem claims, complete member/provider correspondence, process pharmacy claims, and complete adjustments.

Unit Secretary Gero/Psych, Southwest Regional Medical Center •••••/••••• •••••/•••••
Working in all areas of patient support and office support activities which included ordering all labs, prescriptions, x-rays, consultations, chart management, charting vital signs and physicians notes. Prepare reports and records for all kinds of medical conditions, diagnoses, procedures, and treatments, from doctors written and audio-taped notes.


Collector, Textron Financial••••••••••/••••• 8/•••••
Work all accounts from the Mosaix system and the green bar reports to keep accounts less than ••••• days.

Caregiver, Home Instead Senior Care••••••••••/••••• •••••/•••••
To assist and provide the elderly with companionship and one on one human contact to reduce isolation and improve their quality of life in the comfort and familiar surroundings of their homes. To provide help with day to day chores including meal preparation, light housework, shopping and errands.

Provider Service Representative, Humana/PCA••••••••••/•••••/•••••
To assist providers with any questions or concerns that they may have with the claims that they have submitted to PCA for processing and help with all contracting questions and fee schedules.


Customer Service Representative, Circuit City••••••••••/•••••/•••••
To act as the liaison between the customers and the store by resolving customers issues on a nationwide basis. Responsible for taking calls and answering emails from customers, researching their concerns and providing resolutions.

Provider Relations Representative, QualChoice ••••••••••/•••••/•••••
Develops and manages the professional health care services delivery systems for all existing and future products. Work as a liaison between QualChoice and professional providers such as physicians, physician health organizations, physician-hospital organizations, hospital based physicians, pharmacists, and other ancillary providers in order to maintain contractual agreements, provide effective cost control and accomplish effective communication in order to identify and resolve mutual problems. To stay in active contact with all providers in my region and complete site visits. Enter all par and non par providers, enter all rates and pricing areas for par and non par providers, enter all new CPT codes and HCPCS codes and answer incoming calls from providers and help them with referrals or other questions concerning contracts and fee schedules. Maintain the system with the correct information so that the providers claims will process correctly.

Lab Tech II/Phlebotomist, UAMS Clinical Laboratory Temp •••••/3/•••••/1/••••• Perm •••••/1/••••• 6/••••• Temp 5/•••••/••••• 9/•••••
Draw blood, order the test that are requested by the physicians, label the specimens, spin down the blood, aliquot the blood and deliver the specimens to the correct department for processing.

Patient Account Representative/Medicare Billing, St Vincents Infirmary Medical Center 5/••••• •••••/•••••
Bill all Medicare claims primary and secondary to Medicare. Work all claims off the HBOC system that have failed edits. Bill all claims through the SSI system. Work all claims on the T list off the Medicare remote. Work all the EOBs when received. Work all the Age Trail Balance reports, Payment Plan reports, and the Follow Up reports.

Medicare/Medicaid Team Leader, National Medical Systems ••••••••••/••••• •••••/•••••
Working closely with the supervisor and staff. Handling special research projects and processing departmental reports. Overseeing all payments and denials from MCare & MCaid. Review all purge codes, Bill MCare & MCaid in each account for primary and secondary billing. Extensive planning, organizing, evaluating, and following up varied responsibilities in a timely and complete manner.

Office Manager, DRM Family Practice Clinic of Little Rock •••••/••••• •••••/•••••
In charge of bookkeeping, payroll, scheduling, ordering of all office supplies. Review and screen all incoming resumes. Manage correspondence and all travel arrangements and accommodations for physicians. Responsible for all personnel records and benefit information. Developed, revised, updated, and implemented Affirmative Action Plans according to clinic requirements.

Field Representative, Arkansas Medical Lab/Baptist Hospital ••••• •••••/••••• •••••/•••••
Proficient in developing excellent relationships with clients and consultants for recruiting needs. Responsible for recruiting, establishing, monitoring, service and aids in the selection process for potential clients. Giving onsite orientation of the labs policies and procedures to newly contracted facilities. Assist in the phlebotomy process when in the office.

Jr. Assistant Manager, Beall Ladymon •••••8/••••• •••••/••••••••••
I was in charge of the shoes and the childrens departments. I also managed up to ten people in sales, customer service, hiring, and administration. Providing support for our sales staff, implementing new policies and procedures for customer service, and monitoring to see that all sales and service objectives are met. Set and maintained inventory policies, with involvement in purchasing, warehousing, display, and stock handling.

Deli Manager Food Warehouse •••••9/••••• •••••/•••••
Developed new products program, pricing, promotional and sales strategies. Managed up to six deli employees. Introduced new vendor line of products. Responsible for selecting, training, motivating and supervising in deli sales, service and operations.

Manager, Baskin Robbins •••••1/••••• 9/•••••
Responsible for hiring, training, supervising, and directing employees into theyre daily routines. Figuring timecards. Decorated cakes and pies. Greeting each guest in a delightful manner. Do closing paperwork and deposits.

COMMUNICATION SKILLS
I have worked with people on all jobs and recognize how to treat others under normal and irregular situations. I understand the importance of communication in keeping a growing company productive and take pride in creating order in my professional attributes.•••••