Final review of Whole Life and Home Health Policies for completeness and accuracy. Notify writing agent of missing or incomplete applications for review with the policy holder.Enter complete policies into the system and notify the Accounting Department to begin the draft or deposit the funds.Review, correct and mail letters to policy holders. Federal Express large payment claims to Whole Life underwriter for signature and mailing.Distribute daily applications for Home Health and Whole Life Policies, Cancellations, Bank draft changes, corrections to existing policies, Agent supply orders and delivery communications that come through the fax.Prepare and mail policies via Certified Mail.Prepare reports for underwriter regarding Whole Life Annuity policy searches.

National Accounts; Identify and recruit Mental Health professionals, Groups and Facilities requested by our Health plan partners to meet the company’s ever growing member demand. This is done via email, mail and phone. Review the clients’ program descriptions to ensure that they will meet the company’s Medical Necessity Criteria. Travel to areas where large recruitment efforts are being initiated to attend meetings and provide additional support for coverage. Review new and existing contracts from clients for edits and negotiate reimbursement rates. Add additional services that a client may be providing. Walk new clients through the contracting process and ensure all questions and concerns are explained thoroughly.Ensure proper loading of contracts into company’s computer so that claims process according to clients expectation.Create and maintain logs of recruitment efforts and report progress.

Data entered all orders from physicians in the computer system as well as the hospitals. Reviewed the order for completeness and accuracy. Contacted patients’ insurance carrier for eligibility and benefits. Obtained precertification and referrals then contacted the patient within 24 to 48 hours to schedule the Sleep Study at one of five locations for their convenience. Explained the process, and gave preliminary benefit and payment information. Ensured the patient understood the process, and noted any special needs or concerns. Notified ordering physician of scheduled appointments, compliance issues or insurance denials.Communicated frequently with the Lead Sleep Technician on patients’ needs or requests. Ensured patient and staffing ratios were not compromised. Followed up in morning with the previous nights’ staff to ensure all the patients completed, entered the status in the computer, and completed logs.Forwarded the completed report to the dictating physician, ensured a five to seven day turn around on reports. Faxed dictated report to ordering physician. Maintain a completed chart for future reference. Following CMS, JACHO, and HIPPA compliance. Assisted the patient with ordering of Durable Medical Equipment and supplies as needed.Generated weekly reports to Area Manager on number of orders, completions, no shows, cancellations, technical issues, and refusals. Attended weekly and monthly staff meetings to ensure goals were being met.

Managed all areas of 25 groups assigned. Phone conversations with Benefit Coordinators regarding enrollment material, benefit fairs or presentation schedules. Attended Open Enrollment meetings and gave presentations, often to large groups, explained the plan design and answered questions. Attended Benefit Fairs and passed out enrollment material as well.Spoke to members regarding the plan design, questions or concerns, assist with finding attorneys and legal advice, and how the plan will work for them. Conversed with attorneys regarding payment of claims, eligibility, and plan provisions. Processed, interpreted and paid claims for attorneys and membersAnalyzed appeals, processed bank changes, new enrollments, and terminations. Processed a weekly and monthly batch report to track payments and use of the plan. Wrote new policies and procedures to create a more even work flow.

Local Third Party Insurer in Austin, TX. U.S.A.Answered Provider, Member, and Employer calls. Assisted with claims issues, and explained how certain procedures processed and paid according to the plan benefit chosen. Ordered Explanation of Benefits and assisted in the reprocessing of claims through written correspondence. Took payments over the phone and assisted in tracing unapplied payments from providers and employees.Enrolled employees in their benefits chosen by their employer. Explained the applicable laws regarding their plan. Most of the plans administered were under the Section 125 tax code, which has certain stipulations and laws governing them.

Answered customer calls to resolve claims issues, the appeals process, and educated on industry laws and regulations. Explained the plan, how it paid benefits under the ERISA guidelines, and how it corresponds to Medicare and Medicaid.Working knowledge of ICD-9/CPT coding. Analytical skills for processing claims and gathering data.Trained and monitored calls in the call center for quality control. Gave improvement guidelines to better the answer time and resolution time. Took escalated calls to resolve issues and reported resolution to the supervisor of the Member service or Provider Service department. Unresolved issues were reported to the Call Center Manager for follow up.Processed and paid claims according to the Plan Guidelines, documented all incoming correspondence, assisted in the investigation process of Appeals from providers and members, and completed the Pre-Determination/Medical Necessity Process.Assisted other departments as assigned.