Provider Services Representative Resume
Summary : A challenging and rewarding position which will utilize skills and experience. Able to research and analyze data Able to work independently and as a member of a team.
Skills : Microsoft Office, Call Center, Health Insurance.
- Answered inbound provider calls nationwide for subscribers of BCBS Delaware, Pennsylvania and West Virginia medical insurance plans.
- Answered inbound calls from hospitals, medical practices (medical/surgical and dental) and substance abuse/mental health facilities to answer medical policy insurance inquiries.
- Provided up to date benefit quotes stating copay, deductible, coinsurance, and out of pocket values for specific medical procedures.
- Researched cpt codes for various medical procedures giving the accurate benefit quote and supporting medical policies that may influence medical claim approval.
- Reviewed medical policy bulletins if applicable for providers with claim denials.
- Forwarded claims to appropriate departments for review and adjustment when claim denial errors are discovered.
- Explained provider offsets/refunds to providers when payments are recouped for claims paid in error.
B.A. In English
Sr. Provider Services Representative Resume
Summary : Possess extensive experience with a record of success in Customer Service and Marketing. a successful background in training new hire employees and in force management. a creative problem solver with the ability to resolve and troubleshoot client issues and concerns. Management: A solid background in resource analysis and call center management.
Skills : Microsoft Office, Typing, Internet Research, Customer Service, Communications, Team Building, Healthcare, Call Center.
- Maintained and update the NPI database.
- Answered Provider telephone inquiries using an ACD telephone systems and coordinate issues with the assigned Provider Representative.
- Investigated and responded to Provider Claim inquiries.
- Worked closely with and keep supervisor and Director informed of all provider issues.
- Assisted Finance with returned EOP's and checks by researching new mailing addresses for providers and updating system(s).
- Provided the highest possible level of service to clients; - Promote teamwork and cooperative effort among employees; Typing, talking, and researching done for 8 business hours and overtime if needed.
- Maintained safe practices; and - Abide by the Health plan's policies and procedures as they may from time to time be updated.
Health Care Administration
Jr. Provider Services Representative Resume
Objective : To expand overall learning and business experience in order to make a successful viable contribution to a progressive organization serving the organization's mission statement and becoming a more valuable asset employee utilizing extensive educational and business experience with commitment and service excellence to all internal customers, external customers providers and stakeholders.
Skills : Legal Research, Microsoft Excel, Powerpoint, Word.
- Documents and tracks contacts with members, providers and plan sponsors.
- Explains member's rights and responsibilities in accordance with contract.
- Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) via target system.
- Educates providers on our self-service options; Assists providers with credentialing and re-credentialing issues.
- Responds to requests received from Aetna's Law Document Center regarding litigation; lawsuits.
- Handles extensive file review requests.
- Assists in preparation of complaint trend reports.
MS In Industrial
Provider Services Representative III Resume
Objective : Provided liaison support between the provider community and Molina Healthcare of Michigan Inc, as it relates to the delivery of medical services to. Provided continuous education and training of Molina benefits as well as Medicaid guidelines to a Primary Care Network, Hospital providers and the.
Resolved provider claim issues; handled approximately 50-100 inbound call center calls regarding provider participation status, and reprocessing.
Skills : Customer Service, Accounts Receivable, Data Entry.
- Used of reference materials such as SERP, Tax Publications, Form Instructions, IRM's, etc to research information to ensure the taxpayer receives a correct and concise answer to their question.
- Assisted callers in a polite and professional manner at all times when interacting with taxpayers.
- Identified customer issues and sends discrepancy notices to appropriate co-workers, following disputes to satisfactory resolution.
- Resolved customer disputes to ensure overall customer satisfaction.
- Performed weekly billing and generated billing reports on a weekly, monthly, and yearly basis, assisted with monthly, quarterly, and yearly end closing.
- Assisted provider relations representative and maintain accurate phone logs.
- Assisted in educating the providers on claims submission payment procedures and billing issues.
Bachelor Of Science
Provider Services Representative II Resume
Summary : Highly experienced Customer Service professional; with strong analytical, problem solving and research skills. Excellent listening skills, oral and written communication. Comfortable communicating with all levels of the organization and public. Self-motivated, multitasker, and reliable with experience training new staff, managing special projects, and monitoring performances for customer service excellence.
Skills : Call Center Experience, Customer Service.
- Coordinated claims workflow projects.
- Responded to telephone and written inquiries and initiates steps to assist callers regarding issues relating to the content or interpretation of benefits, policies and procedures, provider contracts, and adjudication of claims.
- Adjusted voids and reopens claims on-line within guidelines to ensure proper adjudicate.
- Answered questions for the customer service reps and provides direction on provider calls.
- Determined when adjustments may be due for incorrectly processed claims.
- Analyzed trends and escalates to appropriate department Hires, trains, coaches, counsels, and evaluates performance of direct reports.
- Defined and monitored performance and productivity standards specific to those systems that must be in place to serve provider network and its enrolled population.
BS In Criminal Justice
Provider Services Representative I Resume
Headline : To secure a position where can take on new challenges, offer organizational, leadership and communication skills. As well as, be able to advance within the company.
Skills : Type 65 Wpm, Alpha/Numeric Data Entry, Customer Service, Cashier, Waitress, Word Processing, Internet.
- Worked with providers and their centers and ensuring that they maintain the highest level of Medicare Risk Adjustment compliance, work reports, and correct submittal of encounters.
- Reviewed monthly center date to identify referral trends/patterns and identify high cost patients for discussion/intervention with centers.
- Scheduled center meetings in accordance with servicing metrics.
- Met at least once per month with center PCP/or administrator to review and discuss monthly management reports and YTD performance.
- Recommend corrective action to increase center's quality performance.
- Completed center communication form documenting monthly meetings and submit to manager, provider relations, in follow-up to each meeting.
- Worked in conjunction with center to develop and maintain compliance with MCCI Delivery Systems.
- Monitored compliance to delivery system and provide reports to identify leakage and opportunities for changes and improvements.
Certified Medical Coder
Assistant Provider Services Representative Resume
Objective : Experienced Customer Service Representative who is seeking a full-time permanent position where Customer Service experience will enable me to contribute to a company's success.
Skills : Basic Xray, Medical Assistant, Clinical, Customer Service, Medical Insurance.
- Interfaced with customers via approximately 50 inbound call per day for the purpose of resolving routine problems with products or services.
- Verified health insurance benefits for providers and members.
- Knowledged of Medicare, Medicaid, and individual health insurance plans.
- Followed-up on issues not immediately resolved.
- Processed claims and verifies authorizations and referrals.
- Greeted customers in a courteous, friendly, and professional manner.
- Prepared complete and accurate work and update customer file.
- Effectively transfered misdirected customer requests to the appropriate party.
Associate Provider Services Representative Resume
Headline : Obtain a challenging position with organization that will not only enhance, but continue to develop skills while allowing potential for growth and advancement.
Skills : Microsoft Office, Microsoft Office, Microsoft Word, Microsoft Excel, Data Entry, Filing, Fax, Unix, Lotus Notes.
- Analyzed Tricare Provider contracts to ensure the provider is fully aware of the reimbursement level to be expect.
- Administered telephonic provider education/training for all Tricare Providers Work closely with the credentialing department as a liaison for all new and existing Providers and Beneficiaries.
- Maintained daily electronic documents, files, and record keeping.
- Maintained time and attendance within the provider services department.
- Assisted providers with the policy and procedures within Tricare in regards to funding and contracts in for medical equipment allowances.
- Assisted in provider retention and satisfaction.
- Responsible for department's month-end process to include monthly reporting Ensure that all Provider Services Representative answer the incoming phone calls within the goal marks set.
Certified Medical Coder
Provider Services Representative/Supervisor Resume
Objective : To obtain a challenging position with growth potential and the opportunity to utilize and expand my analytical and interpersonal skills.
Skills : MS Office, Medical Terminology, Billing, Customer Service, Insurance Verification.
- Served as an expert resource for Molina Healthcare in the functional and/or operational utilization of the Health Plan.
- Ensured provider and members are provided top quality education to meet State and Federal goals and guidelines.
- Facilitated resolutions of provider issues, collaborating with internal departments as necessary.
- Assigned to Special Projects.
- Completed the recontracting of providers that participated under other IPA's and no longer participates with the Health Plan.
- Ensured all demographic information is correct on contracted and non-contracted providers.
- Worked collaboratively with Contract Managers in implementing and administering contractual provisions of provider agreement to ensure contractual compliance.
Provider Services Representative Resume
Objective : Found that sales can be challenging but, is one of the most rewarding career fields. Looking to get back into a sales position where make money and love the product(s), Verified correct claim information for providers and adjusted claims if necessary. Updated and verified other insurance for members. Manage flow of information to and from the provider offices.
Skills : Customer Service (10+ years), Microsoft Office (10+.
- Answered inbound calls and assist providers with claims, benefits, and authorizations.
- Properly documented calls in detail while assisting providers.
- Attended department meetings as scheduled.
- Provided assistance to other teammates as needed.
- Handled special projects as needed.
- Ability to remain calm under pressure. Ability to multitask.
- Monitored and communicated market trends and issues.
Certified Medical Coder