Ashley Sommer
Lacey,WA
Summary
Customer Support and Medical Adjudicator Professional
Overview
11
11
years of professional experience
Work History
Medical Treatment Adjudicator
Crime Victims Compensation
Tumwater, WA
06.2018 - Current
- Examine crime victim's claims for the State of Washington and determine payment for medical and mental health bills
- Review diagnosis and procedures billed and make a determination if the billed information correlates to the crime victim's claim
- Determines extent and availability of primary insurance, researches and resolves conflicting eligibility information
- Review and interprets Explanation of Benefits (EOBs) from private/public insurance companies
- Direct the authorization of medical treatment bills and claim adjudication (validity) for sexual assault claims and physical abuse claims
- Receive and initiate telephone calls to providers, victims attorneys, collection companies, public and private insurance companies
- Adjudicate bills based on claimant eligibility and validity of service, reviews ICD-9 diagnosis codes, procedure codes and descriptions of service for appropriateness
- Process adjustments/deductions of processed bills and resolve complex system edits on billing transactions
- Review and respond to written payment protests from providers and processes corrections to original adjudicative decisions when necessary.
- Reviewed and analyzed legal documents, such as pleadings, motions, affidavits, orders and opinions to determine the facts of a case.
- Assisted customers in navigating website and troubleshooting issues.
- Volunteered to help with email-based and phone support to customers when needed.
Medical Treatment Adjudicator Labor and Industries Worker's Comp
06.2015 - 05.2018
- Review bills for payment or denial from various provider types and injured workers, while following the Washington State Medical Rules and Fee schedule
- Handles incoming calls from Claim managers, providers, injured workers and attorneys
- Determine if medical services provided are applicable to workplace injury sustained by injured worker
- Complete adjustment of bills paid or denied bill, Process incoming correspondence from providers, workers or attorneys
- Assist providers, claim managers, and injured workers or attorneys.
Office Assistant 3 Labor and Industries - Tumwater
11.2014 - 06.2015
- Provide exceptional customer service, Multi Line phone use
- Organized office operations and procedures, such as managing calendars, scheduling appointments, preparing reports and maintaining records.
- Mail important documents and letters
- Implemented real-time chat support system, leading to a 40% decrease in response time and a 15% increase in customer satisfaction ratings
- Utilized various software programs such as CRMs, ticketing systems., to provide support.
- Increased customer satisfaction ratings 25% by effectively answering questions, suggesting effective solutions and resolving issues quickly.
Staffing Coordinator Providence St Peter Hospital - Lacey
07.2014 - 08.2014
- Utilize exceptional organization and planning skills to update and monitor daily schedules for multiple departments within the hospital
- Arrange for supplemental staff when necessary
- Collaborated with cross-functional teams to customize Zendesk features to align with company's customer service standards, resulting in a 20% improvement in staffing departments
- Implemented a CRM system to streamline customer interactions, resulting in a 40% increase in full-time staffing for multiple departments
- Implemented advanced scheduling procedures to increase effectiveness and reduce scheduling discrepancies.
Medical Biller
MedAmerica Billing Services
Modesto, CA
06.2013 - 04.2014
- Review and mail HCFAS, Verify patient eligibility and demographics
- Data enter hospital charts, Worker's Compensation verification calls, Accounts Receivable management
- Appeals completion, Denial follow up, Mastered Gov't, County, PPO/HMO, Self-pay, and Commercial insurances
- Reviewing and ensuring all medical documents are accurate and have correct patient information as well as electronic medical charts.
- Provided technical assistance to customers through online chat or telephone support.
- Resolved customer complaints in a timely manner while maintaining a positive attitude.
- Documented all customer interactions and inquiries in the ticketing system accurately and completely.
- Monitored chat queues for incoming requests from customers requiring assistance.
Education
Skills
- MediSoft & Ecode Software
- Medical Terminology
- Medical Transcription
- ICD-9 & CPT Coding
- Telephone Etiquette
- Referrals
- Pre-Authorizations
- HIPAA & OSHA Regulations
- Project Planning and Research
- Daily Operations Support
- Recording support tickets
- Client chat and email support and assistance
Timeline
Medical Treatment Adjudicator
Crime Victims Compensation
06.2018 - Current
Medical Treatment Adjudicator Labor and Industries Worker's Comp
06.2015 - 05.2018
Office Assistant 3 Labor and Industries - Tumwater
11.2014 - 06.2015
Staffing Coordinator Providence St Peter Hospital - Lacey
07.2014 - 08.2014
Medical Biller
MedAmerica Billing Services
06.2013 - 04.2014