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Skills

  • Fraud detection and prevention
  • Report preparation
  • Fraudulent claim prevention strategies
  • Healthcare claims processing systems
  • Compliance with healthcare protocols
  • Receiving support
  • Handling Confidential Information
  • Healthcare provider communication
  • Cross-functional collaboration
  • Professional telephone demeanor

Work Experiences

  • Averaged 5 calls, emails, and faxes per day, answering customer questions, solving problems, and providing product information.
  • Spoke with customers about their concerns about products or services in order to resolve issues and increase sales.
  • Followed all customer call guidelines, such as service levels, handling time, and productivity.
  • Entered customer interaction details into QuickBooks to track requests, document problems, and record solutions offered.
  • Provided primary customer support to internal and external customers in a fast-paced environment.
  • Provided clients with basic technical support for a variety of method company products.
  • Promoted a superior customer experience by responding to customer concerns, demonstrating empathy, and quickly resolving issues.
  • Analyzed customer data to identify problems, develop potential solutions, and ensure high-quality service.
  • Established long-term, loyal customer relationships by providing excellent service and detailed order, account, and service information.
  • Double-checked order data on a two years basis to ensure that transactions and shipping dates were correct.

Summaries

  • Motivated to address customer concerns directly and efficiently, develop proactive solutions, and implement corrections quickly.
  • Customer Service Representative with exceptional oral and written communication, active listening, and problem-solving abilities.
  • Bring extensive high-call volume experience working with framework consumers spanning 9 years.
  • Service-oriented team player with a track record of providing high-quality support in the Miscellaneous for 11 years.
  • To promote high-quality, cost-effective patient care, the Care Review Processor checks eligibility and verifies benefits, obtains and enters data into systems, processes requests, and triages members to health-care services.
  • Care Review Processor proactive with experience in providing support and resolving customer complaints.
  • To build loyalty, employs service-oriented behaviors, understands customer desires, and provides customized solutions.
  • Worker with a strong understanding of method organization and framework product issues.
  • Care Review Processor with 18 years of experience in dealing with customer requests and concerns.
  • Tableau and initiative techniques have been taught to me.

Accomplishments

  • Reduced Medicare claims disputes by 49% through careful review and validation procedures, cutting down resolution delays across the team.
  • Led a cross-functional initiative to revise operating procedures, resulting in a 16% increase in Medicare claims approval.
  • Authored and distributed detailed care review reports, facilitating a 62% rise in claims approval success rate amongst key stakeholders.
  • Conducted thorough care reviews, ensuring compliance with Medicare standards and reducing rejection rates by 55% at standard.
  • Presented detailed data analyses to upper management, leading to the adoption of a new claims review protocol, reducing rejection rates by 38%.
  • Collaborated with sales to strengthen fraud detection tools, contributing to a 16% reduction in flagged claims within 18 months.
  • Collaborated with the IT team to automate patient data entry, reducing overall processing time by 45% in 18 months.
  • Collaborated with team of 5 in the development of standard.
  • Documented and resolved process which led to procedure.
  • Enhanced internal collaboration efforts across the Claims and Billing departments, resulting in a 23% decrease in approval delays.

Affiliations

  • Rotary International
  • International Council of Nurses
  • Case Management Society of America (CMSA)
  • Council for Affordable Quality Healthcare (CAQH)
  • Freemason
  • Patient-Centered Primary Care Collaborative (PCPCC)
  • Toastmasters
  • National Association for Healthcare Quality (NAHQ)
  • Association for Computing Machinery
  • Medical Group Management Association (MGMA)

Certifications

  • Certified HIPAA Security Professional (CHSP)
  • Certified Pharmacy Benefits Specialist (CPBS)
  • Apple Certified Associate (ACA)
  • Medical Auditing Certification provided by Beacon Labs
  • Ethics and Compliance Certification (provided by Cedar Works)
  • Certified Medical Reimbursement Specialist (CMRS)
  • Certificate in Health Insurance Processing and Communication provided by Cedar Works
  • Certified Medicare Secondary Payer Professional (CMSP)
  • ICD-10 Medical Coding Certificate
  • AHIMA Certified Coding Specialist (CCS)

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