JAMIE MCCALL
Phoenix,AZ
Summary
Passionate professional with commitment to supporting clients in all aspects of cases. Excellent communication and relationship building skills with diverse audiences. Friendly and engaging with strong team collaboration abilities. Over 20 years experience in healthcare insurance. Comprehensive experience researching and investigating healthcare claims, handling customer inquiries, claims processing, accounts receivable and problem resolution. Strong analytical and communications skills. Responds promptly to inquiries. Proficient in MS Word, Excel, Outlook, Facets, Emdeon, NextGen, Aces, ECare, ESD, OneView, OneSource, NetSuite, RPA, CMS, ImageRight, Producer Express ICD 9 CM, billing and CPT coding. Always a team player
Overview
25
25
years of professional experience
Work History
Producer Help Desk
United Healthcare
Phoenix, AZ
05.2023 - Current
- Provide sales support to agents for enrollment in Medicare and Medicaid
- Lookup plan information, coverage and cost
- Provide eligibility information for Medicare and Medicaid
- Manage administrative aspects of commissions payments such as tracking, reporting and troubleshooting
- Ensure proper completion of contracts and marketing agreements
- Act as an internal liaison and resource for policy questions and system issues.
Pharmacy Advocate
Cigna HealthCare
Phoenix, AZ
08.2021 - 07.2023
- Provided assistant for customers, provider and pharmacist with pharmacy benefits, claims and prior authorization
- Set up medication overrides, pay pharmacy claims, assist with appeals process
- Work with insurance coverage and benefits
- Calling pharmacies to help with billing for medications
- Explaining state guidelines for medications
Accounts Receivable Specialist
Quadris Team
Phoenix, AZ
06.2019 - 04.2020
- Responsible for Billing, Re-Billing, Post-payment and Account Follow-up and/or grievance preparation of assigned Client Hospital Accounts Receivable
- Working at a Client site, in a Centralized location, or remote the responsibilities may include account maintenance of specialized or multiple payers including state and federal government programs, managed care, commercial and other insurance groups.
Accounts Receivable Specialist
Matrix Medical Health Network
Scottsdale, AZ
07.2018 - 06.2019
- Monitors and maintains assigned accounts through performance of Remittance research and follow-up
- Retrieves, creates, balances, and posts Remittance to corresponding Claims
- Prepares Funds Verification and corresponding Financial Reporting
- Completes Cash and Charge Reconciliations, Post-Payment Reviews, and Denial Management
- Ensures with flexibility, End of Month close is complete, with all available postings finalized last business day
- Performs other assigned tasks and duties necessary to support Accounts Receivable.
Claims Reviewer/Accounts Receivable
Triwest Healthcare Alliance
Phoenix, AZ
01.2016 - 06.2018
- Conducts retrospective review of medical/surgical claims and behavioral health claims for inpatient and outpatient services
- Applies clinical, coding and processing knowledge to conduct review and process claims
- Compiles information necessary to prepare cases program payment
- Ensures adherence to program benefits as authorized
- Validates medical determinations through research of resources including regulatory manuals, computer files and documentation
- Reviews claim data for process improvements related to all aspects of claims payment
- Work and review claims that are not paid properly by the VA.
Claims Reviewer
Aerotek
Phoenix, AZ
09.2015 - 01.2016
- Conducts retrospective review of medical/surgical claims and behavioral health claims for inpatient and outpatient services
- Applies clinical, coding and processing knowledge to conduct review and process claims
- Compiles information necessary to prepare cases program payment
- Ensures adherence to program benefits as authorized
- Validates medical determinations through research of resources including regulatory manuals, computer files and documentation
- Reviews claim data for process improvements related to all aspects of claims payment
Military Service Representative/Enrollment Specialist
United Healthcare
Phoenix, AZ
02.2013 - 08.2015
- Provides excellent customer service to members, physicians, and other staff
- Responds to customer inquiries dealing with complex medical issues and promptly researches the claim
- Handles billing and payment issues, information requests, Explanation of Benefits, authorization for treatment, and physician assignments
- Consistently meets productivity goals, schedule adherence, and quality standards.
Claims Representative/Provider Customer Service Specialist/COB Analyst
Phoenix Health Plan
Phoenix, AZ
08.2008 - 10.2012
- Responsible for processing all assigned claims in accordance with company standards for accuracy, productivity, and promptness
- Checked codes for correct billing procedures including procedure and diagnosis codes
- Denied claims not submitted in the correct format or without proper documentation
- Filed pending claims and processed pending claims after appropriate review
- Investigated and researched claim issues submitted by providers and customers
- Resolved issues in a timely manner and followed-up with originator of the claim issue.
Customer Service Advocate
Anthem Blue Cross & Blue Shield
Richmond, VA
01.2006 - 07.2008
- Provided benefit information to members and providers regarding referrals and authorizations, enrollment, claim processing, membership issues, payments, and benefits
- Abstracted clinical information from a variety of medical records and assigned appropriate ICD 9 CM and/or CPT codes to patient records
- Conducted prompt and thorough investigations by evaluating facts, rendering determinations, and interpreting laws and regulations
- Promoted from a temporary employee to a regular employee.
Quality Control Auditor
Blue Cross & Blue Shield
Phoenix, AZ
07.2005 - 08.2006
- Responsible for performing detailed audits to verify the accuracy of claims processing, inquiries, and other applications
- Reviewed accuracy of enrollment and benefit programming
- Prepared and maintained documentation supporting the audit findings.
Claims/Customer Service Representative
Blue Cross & Blue Shield
Phoenix, AZ
06.2000 - 07.2005
- Handled inquiries from members, providers, and internal staff
- Explained contract benefits, changes in coverage, claims payment and denials to members and providers
- Prepared medical review determinations, handled suspended claims, and corrected edits.
Claims Specialist
Horizon Blue Cross & Blue Shield
Neptune, NJ
06.1999 - 06.2000
- Processed Medicare, dental, hospital, and no-fault claims into computer system along with appropriate physician referral information and accurate medical coding
- Prepared daily production reports and other required documentation
- Adjusted and resolved claims pending issues.
Education
Executive Secretary/Information Processing Certificate -
Katherine Gibbs Secretarial School
Skills
- Claims Processing
- Multitasking Skills
- Benefits & Eligibility
- Investigate Claims
- Problem Resolution
- Communication Skills
- Medical Insurance
- Analytical Skills
- Appeals & Grievances
- Account Receivable
- Referrals & Authorization
- Audits
- Pharmacy
- Benefits Administration
- Document Review
Timeline
Producer Help Desk
United Healthcare
05.2023 - Current
Pharmacy Advocate
Cigna HealthCare
08.2021 - 07.2023
Accounts Receivable Specialist
Quadris Team
06.2019 - 04.2020
Accounts Receivable Specialist
Matrix Medical Health Network
07.2018 - 06.2019
Claims Reviewer/Accounts Receivable
Triwest Healthcare Alliance
01.2016 - 06.2018
Claims Reviewer
Aerotek
09.2015 - 01.2016
Military Service Representative/Enrollment Specialist
United Healthcare
02.2013 - 08.2015
Claims Representative/Provider Customer Service Specialist/COB Analyst
Phoenix Health Plan
08.2008 - 10.2012
Customer Service Advocate
Anthem Blue Cross & Blue Shield
01.2006 - 07.2008
Quality Control Auditor
Blue Cross & Blue Shield
07.2005 - 08.2006
Claims/Customer Service Representative
Blue Cross & Blue Shield
06.2000 - 07.2005
Claims Specialist
Horizon Blue Cross & Blue Shield
06.1999 - 06.2000
Executive Secretary/Information Processing Certificate -
Katherine Gibbs Secretarial School