Jerusha Umar
Toledo,OH
Summary
Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.
Overview
21
21
years of professional experience
Work History
Grievance and Appeals Analyst
Aetna, CVS Health Company
Toledo, OH
10.2022 - Current
- Gather, analyze and report verbal and written member and provider complaints, grievances and appeals
- Prepare response letters for member and provider complaints, grievances and appeals
- Coordinates additional follow up activities with appropriate department managers and/or leads and tracks to conclusion
- Maintains grievance and appeal case files
- Responds to member, provider, client and other inquiries via telephone or written correspondence while meeting all corporate guidelines and client performance standards
- Responsible for coordination of all components of complaints/appeals including final communication to Client for final resolution and closure
- Follow up to assure complaint/appeal is handled within established timeframe to meet company and regulatory requirements
- Demonstrates appropriate customer-care skills such as empathy, active listening, courtesy, politeness, helpfulness, and other skills as identified
- Records, investigates, and resolves member complaints
- Gather, analyze and report verbal and written member and provider complaints, grievances and appeals Prepare response letters for member and provider complaints, grievances and appeals.
- Analyzed and rendered determinations on assigned non-complex grievance and appeal issues
- Utilized guidelines and review tools to conduct extensive research and analyze grievance and appeal issues
- Reviewed, analyzed and processed non-complex grievances and appeals
- Followed department guidelines and tools to conduct reviews
- Represented highest level of expertise required to respond to regulators and media inquiries
Customer Service Representative
Medical Mutual of Ohio
Rossford, OH
10.2021 - 06.2022
- Responded to inquiries from customers via phone, written correspondence and chat
- Improved patient outcomes through value-added services
- Identified and resolved potential processing concerns that may affect members
- Navigated systems and provided customer service in accordance with established expectations and service philosophy.
- Provided primary customer support to internal and external customers
- Maintained customer satisfaction with forward-thinking strategies focused on addressing customer needs and resolving concerns
- Submitted electronic/paper claims documentation for timely filing
- Paid or denied medical claims based upon established claims processing criteria
- Used administrative guidelines as resource or to answer questions when processing medical claims
Remote Medical Coder
ProMedica Health System
Toledo, OH
02.2002 - 06.2021
- Reviewed outpatient records and interpreted documentation to identify diagnoses and procedures
- Guarded against fraud and abuse by verifying coded data accurately reflected services provided
- Reviewed, analyzed and managed coding of diagnostic and treatment procedures contained in outpatient medical records
- Accurately selected proper descriptive code when more than one anatomical location was indicated
- Utilized active listening, interpersonal and telephone etiquette skills when communicating with others
- Correctly coded and billed medical claims for various hospital and nursing facilities
- Applied official coding conventions and rules from American Medical Association and Centers for Medicare and Medicaid Services to assign diagnostic codes
- Reviewed patient charts to better understand health histories, diagnoses and treatments
- Verified signatures and checked medical charts for accuracy and completion
Billing Coordinator
The University of Toledo Physicians
Toledo, OH
07.2007 - 06.2008
- Answered 20+ average daily inbound calls answering questions regarding bills and claims
- Contacted insurance providers to verify insurance information and to obtain billing authorization
- Verified and updated patient demographics and provider data
- Processed and sent invoices, adjustments and credit memos to customers
- Investigated and resolved issues to maintain billing accuracy
- Completed documentation, reports and spreadsheets of financial information.
Education
Certificate - Chemical Dependency Counselor
Owens Community College
Perrysburg, OH05.2021
Diploma - Medical Practice Insurance Billing and Coding
Davis College
Toledo, OH2007
High school diploma - General Studies
Roy C. Start
Toledo, OH2000
Skills
- Medical Coding
- Medical Billing
- Insurance Verification
- Data Entry
- Quality Assurance
- Computer skills
- Client Interviewing
- Claims Reviewing
- HIPAA and Confidentiality Compliance
- Patient Information
- Extensive Research
- Letter Writing
- Customer Satisfaction
- Service Quality
- Conceptual Thinking
- CMS Guidelines
Timeline
Grievance and Appeals Analyst
Aetna, CVS Health Company
10.2022 - Current
Customer Service Representative
Medical Mutual of Ohio
10.2021 - 06.2022
Billing Coordinator
The University of Toledo Physicians
07.2007 - 06.2008
Remote Medical Coder
ProMedica Health System
02.2002 - 06.2021
Certificate - Chemical Dependency Counselor
Owens Community College
Diploma - Medical Practice Insurance Billing and Coding
Davis College
High school diploma - General Studies
Roy C. Start
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