Customer Service Team Member
Resume:
Jan Bailey- Smith
*** ****** **** ***** *******, Florida 32835
407-***-**** ad75gu@r.postjobfree.com
Summary of Qualification
*Extensive Multi-Line Claims and Appeals experience: Inception to Final Resolution
*Extensive customer service, investigations, research and troubleshooting experience, Managed care, appeals, collections, credentialing, contract compliance, grievance resolutions and Worker’s Compensation
*Strong ability to work within a team member or independently with minimal supervision.
Education
MBA – Public Administration Strayer University Graduate 12/2019
Bachelor of Science in Paralegal Everest University Graduated 11/2014
Skills
*Multi-Line claims processing, adjuster and billing (From inception to final resolutions) which includes appeals and grievances: *Auto/PIP, Bodily Injury/Med-Pay, Commercial, Endorsements, FNOL, FSA, Homeowners, Medicaid/Medicare, Property Casualty, General Liability, Boiler Machinery, Umbrella and Worker’s Compensation. Claims Systems to include - EDI/Emdeon, CPR+, AXIS, NextGen, Legacy, Blue 3, Intra-Plan Messaging System, BPM Framework, Call Care Browser, Citrix, Cerner, Facets, GPOO, GUI System, IPD Ultera, ITS, Legacy, Great Plains, Infosys, NASCO, NextGen, PLEDGE, TAP, WGS, OnDemand, CareVoyant, Mediformatix, ZirMed; CISCO, Availity, *Microsoft Office Applications, Desktop Agent Telephone System
*EDI & EHR, ICD-9/10, CPT, HCPC coding, OSHA and HIPPA Certifications and Credentialing; Scheduling, CMS Compliance.
*CMS Medicare and Medicaid Appeals and Grievances
Certification
First Coast University (CMS) - Medicare/Medicaid CEU Training
State of Florida 620 – All Lines Claims Adjuster (2013)
State of Florida 440 - Certified Professional Service Representative (2007)
OSHA and HIPAA Certification
CPCU Designation – Currently pursuing – Actuary, Fraud, Risk Management & UW
EMPLOYMENT HISTORY:
AdventHealth-CentraCare 03/2017 –01/2019 PFS Reimbursement Specialist II
*Responsible for processing and billing medical insurance claims.
*Reviews assigned EDI claims error and EHR A/R reports
*Review EOBs for additional coverage to calculate secondary and tertiary billing
*Research and reprocess corrected claims, proof of timely filing, appeals, write-offs.
*Resubmission of corrected/rejected claims, Medical records via EHR.
*Communication with patients and vendors for claim status and corrected claim data.
ACS-Omnicare, Orlando, FL 10/2015 – 04/2016 Biogen Client Specialist II
*In-depth knowledge of Multi-insurance plans to include PBMs and major medical.
*Conduct prior authorizations, appeals. and copay assistance plans.
*Knowledge of Medicare/LIS status programs
*Ability to work in a fast-paced environment
*Review EOBs for additional coverage to calculate secondary and tertiary billing
*Process medical claims from inception to final resolution
Clermont Radiology, Orlando, FL 08/2011-8/2014 Claims Adjuster/Collection Manager
*Process claims from inception to final resolutions including aging A/R.
*Acquire information and authorization to file letters and post remits
*Review EOBs for additional coverage to calculate secondary and tertiary billing
*Research and reprocess corrected claims, proof of timely filing, appeals, write-offs.
*Claims-FEP Worker’s Compensation, MVP/PIP, Managed care, and Medicaid/Medicare.
ALERE, Inc., Orlando, FL 04/2010-08/2011 Billing & Claims Collections Specialist
*Claim entry, billing/collections aged A/R and patient responsibility accounts.
*Review EOBs for additional coverage to calculate secondary and tertiary billing
*Research and reprocess corrected claims, proof of timely filing, appeals, write-offs.
*Prepare and process secondary and tertiary claims via EDI and EHR systems.
*Process corrected claims, proof of timely filing, initiate appeals, write off dead claims.
* Medicare/Medicare, Managed Care and Worker’s Compensation claims
Anthem-WellPoint, Worthington, OH 09/200801/2010 Claim Adjuster
*Address providers inquiries of claims, adjustments, and final resolution remittances
*Examined incorrect clams and reprocessed based on contractual rates.
*Review EDI and paper claims for correct ICD-9 and HCPC codes for proper billing
*Process major medical claims to include Medicare/Medicaid, Managed Care and
Worker’s Compensation; Research, correct/reprocess claims in a timely manner for remit.
*Generate, research and process claim determination and additional information letters to proceed with claim settlement or appeal for final resolution.
VOLUNTEER SERVICES:
The Black Butterfly Initiative 2000 – Current President and Chief-Executive Officer
This program was created to address the many needs of individuals and families which have fallen through the cracks in terms of not being qualified for specific programs and or services. Our program is directed toward those who openly demonstrates the will and the need to transition from dependency onto self-sufficiency i.e. being fully trained to acquire above minimum wage annual salaries, defeat the ploy of poverty, acquire housing, extract themselves and their families from generational cycles of illiteracy, hunger, homelessness and overall poverty.
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