Claims Benefit Specialist Resume Houston, TX - Hire IT People

SUMMARY

Focused and results - driven healthcare specialist wif over 15 years dedicated experience in the healthcare industry.
Highly qualified in reviewing, analyzing and interpreting insurance policies. Hands on experience in monitoring and managing disbursement of payments.
In depth noledge of coordinating surgery facility and physician schedules.
Ability to conduct investigations utilizing my critical thinking and problem solving skills to collect on insurance claims.
Capable of communicating efficiently using both written and verbal communication skills.
Enjoy working wif internal and external customers to resolve issues or concerns.
Strong analytic skills in gathering and interpreting information presented to draw conclusions on cases.
Strong medical terminology skills paired wif claims processing and medical collections skills.
Ability to build rapports for favorable negotiations on collecting payment or determining an appropriate fee for service.
Professional customer service noledge showing empathy and concern for my customer.
Proficient support services including answering multi-lined telephones, managing mail, type/word processing of documents/correspondence, creating reports, managing calendars, coordinate travel arrangements and schedules.
Make copies, fax, greet visitors, greet patients, set up files, track expenses, and coordinate building and equipment maintenance.
MS Office Suite 1997-2007; EPIC; 10-Key; MS Project; Outlook Express; Lotus Notes; Type 50-55WPM; Internet Savvy.

PROFESSIONAL EXPERIENCE

Confidential, Houston, TX

Claims Benefit Specialist

Responsibilities:

Analyzed and approved medical or dental claims that cannot be auto adjudicated Medicare lines of business.
Applied medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and applies all cost containment measures to assist in the claim adjudication process.
Coordinated responses for routine phone inquiries and written correspondence related to claim processing issues.
Routed and triage complex claims to Senior Claim Benefits Specialist.
Utilized all applicable system functions available ensuring accurate and timely claim processing service (i.e., utilizes Claim Check, reasonable and customary data, and other post-containment tools).
Provided customer service in call center environment to providers and members resolving claims and benefits questions.
Actively listened and resolved complaints using de-escalation skills to prevent further action.

Confidential, Spring, TX

Assistant Manager

Responsibilities:

Staffed restaurant and ensured employees received proper training; ensured that all company standards were met; company policies and procedures were followed.
Ensured costs were properly controlled; Held meetings wif staff; complied wif all labor, health department and corporate codes.
Communicated clearly wif the employees and supervising them effectively to ensure their assignments were completed properly.
Accurately completed inventory supplies and reordered items; Observed and guided employees as they performed their assignments, reallocated labor and coordinated overall operations.
Ensured that guests were served quickly and efficiently; solicited guest feedback and resolved guest complaints; exhibiting a friendly and enthusiastic attitude while showing a caring attitude for guests and employees, while maintaining the company’s operational quality and cleanliness standards.

Confidential, Sacramento, CA

SENIOR QUALITY ANALYST / CORE MEASURE COORDINATOR DUTIES:

Responsibilities:

Performed concurrent data review for current core measures wifin deadlines and assists wif data abstraction as needed.
Prepared requested reports regarding the findings/outcomes of the core measures using problem solving and analytic skills.
Referred information gatheird from medical record review to the appropriate department director for analysis and corrective action to improve quality outcome.
Assisted in review of concurrent data for internal sources to identify issues requiring follow-up.
Provided findings and summaries of concurrent data collection activities for department director.
Presented recommendations based on findings using advanced level of Excel and Power point for reports as well as presentations.
Advised hospital staff, medical staff and/or communities regarding opportunities and methodologies for improvement.
Communicated appropriately and clearly to physicians, staff, and administrative team.
Attended the clinical team meetings to report findings from the core measures involving nurses to obtain/input data.
Acted as core measures/performance improvement resource to hospital and medical staff.
Utilized EPIC system and abstracted core measure data from charts to enter data findings in to the Solucient database on a quarterly basis ensuring the facility meets the Joint Commission regulations.
Maintained and complied wif audits, HIPAA, best practices and internal controls.