JAQUETTA MACK
Tampa
Summary
Analytical problem-solver with excellent communication skills. Effective at interviewing claimants, compiling records and documenting findings. Well-versed in insurance policies, practices and standards.
Overview
6
6
years of professional experience
Work History
Claims Representative
Humana Military- Tricare East
04.2023 - 10.2023
- Maintained a detailed understanding of the organization's payer mix and reimbursement rates, providing key insights during budget planning or forecasting discussions
- Interact with physicians and other patient care providers regarding billing and documentation policies, procedures, and regulations
- Work with VA hospitals, clinics, facilities and the clinical team to manage requests for services from members and/or providers
- Manage the referral process, processing incoming and outgoing referrals and prior authorizations, including intake, notification and census roles
- Provide appropriate triage and care coordination notification cases for non-clinical assessment/intervention
- Handle resolution/inquiries from provider
- Responsible for administering claims payments, maintaining claim records
- Monitors and controls backlog and workflow of claims
- Manage all aspects of insurance billing and processing including claim review and correction
- Ensures accurate and timely submission of claims, follow up on outstanding accounts, work all denials and assist patients with billing inquiries and collections
Member Relationship Specialist II
WellCare/Centene
04.2020 - 10.2022
- Resolve customer inquiries via telephone and written correspondence in a timely and appropriate manner
- Reference current materials to answer escalated and complex inquiries from members and providers regarding claims, eligibility, covered benefits and authorization status matters
- Provide assistance to members and/or providers regarding website registration and navigation
- Educate members and/or providers on health plan initiatives Provide first call resolution working with appropriate internal/external resources, and ensure closure of all inquiries
- Document all activities for quality and metrics reporting through the Customer Relationship Management (CRM) application
- Process written customer correspondence and provide the appropriate level of follow-up in a timely manner
- Research and identify processing inaccuracies in claim payments and route to the appropriate team for claim adjustments
- Identify trends related to member and/or provider inquiries that may lead to policy or process improvements that support excellent customer service and impact quality and performance standards
- Work with other departments on cross functional tasks and projects
- Maintain performance and quality standards based on established call center metrics including turn-around times
- Mailing or Faxing Materials as requested
Scheduling Specialist/Customer Service
Physician Partners of America
10.2019 - 05.2020
- Assisted customers with a warm and professional attitude
- Assisted customers with questions
- Handled emails, inbound calls, and outbound calls
- Booked appointments
- Handled billing issues and order inquiries
- Managed customer accounts
- Kept records of customer complaint
- Create Chart for new patient
- Mailing new pt package
Claims Denials & Follow-Up Rep - Revenue Cycle
Orlando Health Hospital
07.2017 - 02.2019
- Follow up on unpaid claims to the point of payment or resolution of the claim, and resolving credit balances
- Responsible for resolving all outstanding insurance account receivables
- Knowledge of CPT, HCPCS and ICD billing codes, authorization requirements and related documentation
- Completes full-cycle insurance billing operations for and acts as the primary point of contact for5-7 client accounts
- Submits claims in a timely fashion and reviews outgoing claims before submission to identify errors and potential rejections
- Processes insurance and patient refunds as necessary
Education
High School Diploma - undefined
Hillsborough High School
Tampa, FL06.2011
Skills
- ICD-10 Coding Familiarity
- Medical Appeals
- Handling Insurance Verification
- HIPAA Compliance Knowledge
- Claims processing experience
- Medicare and Medicaid knowledge
- Benefit Coverage
- De-Escalation Techniques
- Records Maintenance
- Claims analysis
- Utilization Review Experience
- Eligibility Determination
- Microsoft Office
- Telephone Etiquette Assertiveness
- Professionalism and Ethics
- Issue Research
- Call Center Operation remotely
- Decision-Making
- Data entry
- Professionalism and Ethics Workflow Management
- Accuracy and Precision
- Customer service
- Problem Solving
- Client Relations
- Teamwork and Collaboration De-Escalation Techniques Building rapport
- Scheduling
- Billing Software
LANGUAGES
English
Timeline
Claims Representative
Humana Military- Tricare East
04.2023 - 10.2023
Member Relationship Specialist II
WellCare/Centene
04.2020 - 10.2022
Scheduling Specialist/Customer Service
Physician Partners of America
10.2019 - 05.2020
Claims Denials & Follow-Up Rep - Revenue Cycle
Orlando Health Hospital
07.2017 - 02.2019
High School Diploma - undefined
Hillsborough High School
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