Medical Customer Service
Resume:
Vince Blumberg
Rancho Cordova, CA, 95670
abmdis@r.postjobfree.com
OBJECTIVE
Seeking a stable growth opportunity that will allow me to leverage my
skills and experience. Looking to relocate.
SKILLS & QUALIFICATIONS
. MS Word
. Excel
. Lotus notes
. Outlook Express
. MACESS electronic Doc Flo
. Various company proprietary software
. Type 60+ wpm
. Ten key by touch 100**-***** ksph
. A total of eight or more years in various call center environments
handling accounts for Healthnet, Prudential, Well Fargo, JC Penneys,
AT&T tdd operator for the deaf, as well as many other clients.
. Approximately five years in the health insurance sector in various
capacities. This includes two years call center experience in
healthcare insurance. Processed outsourced medical claims for EDS for
Medi Cal, Medicare, Blue Cross, Blue Shield, Healthnet, United, etc.
Audited dental claims for Delta Dental.
Recently completed a medical record coder specialist certificate program
which I started in 2004 taking courses on an ad hoc basis. After receiving
my coding certificate in June of 2009, I completed a CCA exam preparation
course to take the CCA exam to become CCA certified. I can abstract raw
data from medical records and code them in ICD9 and CPT according to UHDS
sequencing standards. I have experience utilizing the Quadramed
encoder/grouper software for coding applications. I understand
medical/dental terminology, anatomy, and procedures.
EXPERIENCE
Synova, Smithfield, MI
Claims Examiner, 04/09/10-07/2/10
. Provided services to HP manually pricing Medi Cal medical supply
claims. Same location and position as the last assignment.
Volt Services, Roseville, CA
Claims Examiner, 08/27/09-11/30/09
. Manually price Medi Cal medical supply claim billing submissions for
HP utilizing vendor invoicing or catalogs.
. Determine price per unit and total order amount by mathematical
computation
. Pay and or deny Medi Cal medical supply claims based on claim
submittal criteria.
. Met and exceeded productivity/error rate benchmarks.
Insurance Overload Services, Sacramento, CA
Dental Claims Examiner, 03/10/08-01/08/09
. Audit, process and adjudicate dental claims for Delta Dental.
. Determine COB i.e primary or secondary based on a variety of factors
such as family, custodial status, etc, and process accordingly.
. Receive claims in MACESS DOC FLO queue. Clear edits by conducting
research in order to follow the specific dental procedure
guidelines.
. Follow specific guidelines for each type of edit.
. Follow procedural guidelines to determine whether claims should be
paid, denied or rerouted to professional review for further analysis.
. Proofread and verify that information on claim form matches what is
in the database for patient.
. Conduct research on dental providers to verify correct geographical
and dental license status information.
Superior Staffing, Sacramento, CA
Eligibility Representative, 10/06-11/07
. Provided services to Healthnet receiving incoming calls from insurance
broker and group administrators regarding small business group health
plans.
. Process small business group employee enrollment applications on an as
needed basis such as canceling, adding, enrolling and switching
members from different medical plans per policy guidelines.
. Determined COB based on a variety of factors such as family status,
eligibility effective date, birthday rule etc.
. Research analyze, and apply solutions to problem eligibility issues
according to small business group eligibility guidelines which
included placing outbound calls to insurance brokers and group
administrators.
. Reconciled billing account ledgers with eligibility information per
request by explaining billing adjustments and how they impacted
members eligibility on the plan in addition to answering questions in
regards to payment verification of monthly premiums and explanation of
bill.
. Met and exceeded minimum productivity benchmarks on a weekly basis.
. Provided assistance and information from insurance eligibility to
billing of the small business group health plans.
. Explained rules of COBRA to brokers and administrators.
. Coordinate with COBRA TPA in process of research and inquiry for
resolution of COBRA eligibility issues.
. Coordinate with pharmacy TPA to update member pharmacy eligibility on
an as needed basis.
. Electronically process and submit exceptions to supervisor for problem
eligibility issues review.
. Electronically submit requests for HIPAA certificate per member
request.
. Fax out requested bills to small business groups
. Communicate through intranet e mail Lotus Notes or phone with various
other Healthnet departments.
. Utilize Excel spreadsheet to keep track of daily work load inventory
. During the tenure of the assignment, approximately five positive
commendations were accrued from clients to my supervisor. Three were
verbal and two were written, expressing satisfaction in going above
and beyond in one stop solution client customer service.
Superior Staffing, Sacramento, CA
Medical Claims Data Entry 8/24-10/06
. Input Medi-Cal claims financial information into Excel spreadsheet or
EDS.
Rush Personnel Services, Chico, CA.
Medical Claims Processor 04/2005-08/24/06
. I provided services through this agency to EDS (Electronic Data
Services) the billion dollar global company started by Ross Perot. The
division processes outsourced medical claims from the federal
government through Medicare, Blue Shield, Healthnet, etc.
. Processed claim billing submissions from the medical billers on the
provider side. I see the same EOB's and EOMB's that the medical
biller does processing HCFA 1500 and occasional UB92 medical claim
billing submissions. In the flowchart of the claims process I was the
intermediary between the medical biller and the insurance company
proofreading and editing any mistakes the medical billers made so a
"clean" claim could be presented to the insurance company in a
comprehensible fashion.
. Processed hundreds of claim billing submissions a day in a high volume
environment meeting the production quotas for the most important
regions that EDS services with averaged accuracy of not more then 3%
error rate
. Input financial information from the claim forms.
. Utilize Excel spreadsheet for certain claims to determine allowable
amounts.
Avenues, Valencia,CA
Community Support person, 9/2004 - 03/2005
. Provide living skills training and support to people in their own
home, neighborhood, community and job site. Under the supervision of
the Support Services Coordinator support is provided to individuals
who have one or more of the following challenges or needs:
psychological support,physical challenges, and developmental
disabilities.
Mercadante Parent Vendors, Valencia, CA
Staff Support Person, 01/2004-03/2005
. Provide various types of one to one support to individual client with
disabilities in daily living activities. rovided living skills
training and support to people in their own home, neighborhood,
community and job site. Under the supervision of the Support Services
Coordinator support is
L.A County Office of Education, Downey, CA
Substitute Teacher, 04/ 2002 - 03/2005
. Instruct and supervise students in special education with various
moderate to severe disabilities.
L.A County Office of Education, Downey, CA
Substitute Paraeducator, 1998 - 2002
. Assist teacher in special education in conducting classroom
activities.
Prudential Insurance, Los Angeles, CA
Medical Claims Analyst, 07/ 1997 - 07/1998
. Handle telephone inquiries from medical providers and policyholders
regarding medical insurance eligibility, medical claims status and
other claims issues.
. Answer inquiries from policyholders and providers on billing claims
submissions from various medical entities.
. Provide information on benefit coverage for various types of
Prudential health plans. Research medical claims issues in
response to informational inquiries by accessing and interpreting
EOB's and claims history.
. Conduct research, analyze, and troubleshoot claim billing submissions
by coordinating with policy holders and healthcare providers to ensure
timely payment of claims, and that services being paid for are
covered by the policy. Proofreading for mathematical mistakes before
claim disbursements are released.
. Exceptionally high incoming call volume and case load required
extensive verbal/ written, work flow time management, and multitasking
abilities.
. Production and accuracy benchmarks were met and exceeded on a weekly
basis.
. Utilize Excel spreadsheet for certain claims.
EDUCATION
Cal State Northridge, B.A Liberal Studies, 06/2000, gpa 3.25
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