James Gore
Houston
Summary
Detail-oriented Medical Claims Processor with proven expertise in problem-solving, quality assurance, and time management. Committed to enhancing accuracy and efficiency in claims processing.
Professional with experience in healthcare administration, specializing in processing and managing medical claims. Skilled in data analysis, claim adjudication, and ensuring compliance with industry regulations. Strong focus on teamwork and achieving results through effective communication and adaptability to changing needs. Reliable and efficient in handling high volumes of claims while maintaining accuracy and confidentiality.
Overview
17
17
years of professional experience
Work History
Medical Claims Processor
Moda Health
Houston, TX
11.2022 - Current
- Processed medical claims with high accuracy, ensuring compliance with industry regulations.
- Reviewed and adjudicated claims to determine eligibility and benefit coverage.
- Resolved discrepancies in claims by collaborating with healthcare providers and internal teams.
- Developed training materials for new team members, enhancing onboarding efficiency.
- Mentored junior staff on best practices for claims processing and customer service standards.
- Processed high volumes of medical claims accurately and efficiently under tight deadlines, ensuring prompt payment for services rendered.
- Researched and resolved complex medical claims issues to support timely processing.
- Managed large volume of medical claims on daily basis.
- Evaluated medical claims for accuracy and completeness and researched missing data.
COVID-19 Tester
Crosby, TX
05.2022 - 05.2022
- Conducted COVID-19 testing procedures in accordance with safety protocols and guidelines.
- Collected and processed samples efficiently to ensure timely results for patients.
- Maintained cleanliness and organization of testing area to enhance workflow efficiency.
- Provided accurate information to individuals regarding testing processes and results.
- Assisted in training new staff on testing procedures and safety measures.
- Monitored inventory levels of testing supplies, ensuring availability for operations.
- Kept supplies organized and well-stocked, requesting more supplies and avoiding unnecessary testing delays.
- Set up, maintained and verified sterility of lab equipment and tools.
Pharmacy Technician
Kroger
Houston, TX
05.2017 - 04.2021
- Assisted pharmacists in dispensing medications accurately and efficiently.
- Conducted inventory management to ensure optimal stock levels and availability of medications.
- Processed prescription orders using pharmacy software to enhance workflow efficiency.
- Educated patients on medication usage, potential side effects, and adherence strategies.
- Collaborated with healthcare team to resolve medication-related inquiries and issues promptly.
- Maintained clean and organized pharmacy environment in compliance with safety regulations.
- Trained new staff on operational procedures and customer service standards effectively.
- Answered incoming phone calls and addressed questions from customers and healthcare providers.
- Implemented process improvements that streamlined prescription filling and enhanced patient satisfaction.
- Stocked, labeled, and inventoried medication to keep accurate records.
- Calculated dosage, filled prescriptions, and prepared prescription labels with absolute accuracy.
- Promoted patient confidentiality by adhering to HIPAA regulations when handling personal information during transactions.
- Liaised with other pharmacies to eliminate issues related to product expiration.
- Precisely measured and combined ingredients to deliver scrupulous formulation on customer compound prescription orders.
- Monitored ordering of pharmacy medication stock to maintain streamlined inventory and low overhead.
- Managed opening and closing duties for pharmacy.
Pharmacy Technician Trainee
Kroger
Houston, TX
02.2017 - 05.2017
- Assisted pharmacists in filling prescriptions accurately and efficiently.
- Maintained cleanliness and organization of pharmacy workstations and inventory areas.
- Provided customer service by answering questions regarding medications and services available.
- Learned proper storage techniques for pharmaceuticals to ensure compliance with safety regulations.
- Supported team members in managing medication inventory through regular stock checks.
- Processed prescription orders using pharmacy management software to enhance workflow efficiency.
- Followed safety protocols during medication preparation, minimizing errors and ensuring patient safety.
- Collaborated with healthcare professionals to streamline patient care processes within the pharmacy environment.
- Handled confidential patient information with discretion, upholding strict HIPAA regulations at all times during tenure as a Pharmacy Technician Trainee.
- Collaborated closely with pharmacy team members to consistently deliver high-quality care to patients.
Pharmacy Clerk
Kroger
Houston, TX
01.2014 - 05.2017
- Assisted customers in locating medications and products, ensuring a positive shopping experience.
- Processed prescription orders accurately, maintaining compliance with pharmacy regulations.
- Managed inventory levels, restocking shelves to meet customer demand efficiently.
- Collaborated with pharmacists to verify medication accuracy and provide customer information.
- Operated point-of-sale systems for transactions, enhancing checkout efficiency and accuracy.
- Maintained cleanliness and organization of pharmacy area to ensure safety and accessibility.
- Trained new employees on pharmacy procedures, policies, and safety protocols to ensure consistent quality across the team.
- Facilitated clean and organized pharmacy environment, adhering to health and safety regulations.
- Managed cash register and financial transactions, securing accurate payment processing.
Janitor
Kroger
Houston
01.2010 - 05.2015
- Maintained cleanliness and sanitation standards in high-traffic areas.
- Operated cleaning equipment, including floor scrubbers and vacuums, efficiently.
- Disposed of waste materials in compliance with safety regulations.
- Restocked supplies and ensured availability of cleaning materials for team use.
- Conducted routine inspections to identify maintenance needs and report issues promptly.
- Assisted with training new team members on cleaning procedures and safety protocols.
- Collaborated with management to improve overall facility cleanliness and safety measures.
- Reduced the spread of germs by sanitizing high-touch surfaces such as doorknobs and handrails.
Checker
06.2009 - 12.2010
- Inspected incoming and outgoing shipments for accuracy and quality compliance.
- Recorded inventory levels and documented discrepancies in stock.
- Operated scanning equipment to track product movements efficiently.
- Collaborated with team members to ensure timely order fulfillment.
- Implemented best practices for safe handling of products during checks.
- Assisted customers with bagging their purchases, providing swift and attentive service.
- Processed both cash and card purchases and returns.
- Assisted with unloading customer carts onto conveyor belt.
- Collaborated with team members to streamline workflow and improve overall store efficiency.
Courtesy Clerk
Kroger
Houston
01.2009 - 04.2009
- Provided exceptional customer service while assisting shoppers with inquiries and product location.
- Stocked shelves efficiently, ensuring optimal product availability for customers.
- Maintained cleanliness and organization of store areas to enhance shopping experience.
- Operated cash register accurately, processing transactions and handling payments swiftly.
- Bagged customer items efficiently using proper techniques to protect delicate items and separate different groups of merchandise.
- Helped customers take merchandise out of store and loaded items into vehicles.
- Improved customer experience by offering assistance with locating products throughout the store when needed.
- Assisted customers with large purchases by carrying items to vehicles.
- Returned unwanted items to correct store locations and restocked shelves.
- Supported cashier operations by efficiently retrieving shopping carts and baskets for customer use.
- Assisted elderly or disabled customers with loading groceries into vehicles upon request, demonstrating compassion and care in all interactions.
Education
Combination Welder - Welding
San Jacinto College
Pasadena, TXHigh School Diploma -
North Shore High School
Houston05-2007
Skills
- Critical Decision-making
- Quality assurance checks
- Medical Terminology Familiarity
- Fraud detection skills
- Teamwork and collaboration
- Problem-solving
- Time management
- Attention to detail
- Problem-solving abilities
- Organizing and prioritizing work
- Verbal and written communication
- Relationship building
- Computer proficiency
- Recordkeeping organization
- Laboratory analysis proficiency
- Public health
- Chemical handling
Timeline
Medical Claims Processor
Moda Health
11.2022 - Current
COVID-19 Tester
05.2022 - 05.2022
Pharmacy Technician
Kroger
05.2017 - 04.2021
Pharmacy Technician Trainee
Kroger
02.2017 - 05.2017
Pharmacy Clerk
Kroger
01.2014 - 05.2017
Janitor
Kroger
01.2010 - 05.2015
Checker
06.2009 - 12.2010
Courtesy Clerk
Kroger
01.2009 - 04.2009
Combination Welder - Welding
San Jacinto College
High School Diploma -
North Shore High School