Processed Blue Card membership, professional and hospital claims and handled customer service needs for Blue Card. Provided Home and Host customer service to local providers and out of area plans. Resolved problems for members and provider utilizing knowledge across all the lines of business Claims, Membership and Customer Service. Conducted analyses using spreadsheet data for complex high dollar hospital claims and remittance issues. Coached less experience staff to claims processes, Customer Service resolution and idiosyncrasies from uploading or pulling in claims from other states which lent themselves to odd glitches. Identified many system process errors lending themselves to duplicate high dollar pay outs by our company. Many times, supervisor would have me work directly with the Configuration Team to provide
…show more content…
Reconciled complex client to clinical care time payroll and billing statements. Submitted claims via electronic system to Medicaid, CMS and other Commercial vendors. Wrote complete policy and procedures manual. Built and developed a comprehensive tracking system to ensure each step of Minimum Data Set assessments were completed timely. Created a Comprehensive Quality Assurance program. Interviewed, hired and managed nurses, social workers, CNAs and NA’s, office staff and all area supervisors. Audited Physician, Nursing and CNA progress notes and Care plans to ensure records complete and documentation accurate in accordance with Medicare laws. Worked under supervision of nurses and physicians to call pharmacies and relay and receive patient medication orders and PT, OT and ST orders. Worked directly with Medicare and Medicaid auditors to correct any facility tags and ensure policies updated to prevent future
Reconciled complex client to clinical care time payroll and billing statements. Submitted claims via electronic system to Medicaid, CMS and other Commercial vendors. Wrote complete policy and procedures manual. Built and developed a comprehensive tracking system to ensure each step of Minimum Data Set assessments were completed timely. Created a Comprehensive Quality Assurance program. Interviewed, hired and managed nurses, social workers, CNAs and NA’s, office staff and all area supervisors. Audited Physician, Nursing and CNA progress notes and Care plans to ensure records complete and documentation accurate in accordance with Medicare laws. Worked under supervision of nurses and physicians to call pharmacies and relay and receive patient medication orders and PT, OT and ST orders. Worked directly with Medicare and Medicaid auditors to correct any facility tags and ensure policies updated to prevent future