Lei'Ana Franks
Stockton,CA
Summary
Qualified Claims Representative versed in investigating claims, verifying information and managing settlements. Friendly and upbeat team player with organized and disciplined approach. Offering 5+ years of insurance experience.
Gifted in working with stressed, confused and upset individuals in need of benefits information and supportive guidance to navigate systems. Effective at operating within regulations and department guidelines to manage telephone calls, emails, letters and in-person requests for assistance. Highly trained professional with a background in verifying insurance benefits and creating appropriate patient documentation. An established Insurance Verification Specialist known for handling various office tasks with undeniable ease.
Overview
10
10
years of professional experience
Work History
Claims Representative
Blue Shield Of CA
01.2021 - Current
- Enhanced claim processing efficiency by streamlining workflows and implementing best practices.
- Reduced turnaround time for claim settlements by prioritizing tasks and managing deadlines effectively.
- Evaluating claims to ensure payments are service rendered.
- Analyze members medical information and coordination of benefits with other carriers
- Research check, credit card, and EFT exceptions on a daily basis
• Verify eligibility, CPT codes, and ICD-10 codes on claims
• Reconcile electronic postings for applicable payors
• Replied to provider payment inquiries and provided explanation of payment - Review, examine and direct processing of claims & appeals for all lines of business.
- High call volume & accurately document every encounter and outcome while WFH.
- Researched and analyzed complex claims to determine next steps and possible outcomes.
- Maintained strong knowledge of basic medical terminology to better understand services and procedures.
- Calculated adjustments, premiums and refunds.
- Resubmitted claims after editing or denial to achieve financial targets and reduce outstanding debt.
Healthcare Customer Service Representative
Point Quest Pediatrics
02.2016 - 11.2020
- Enhanced patient satisfaction by efficiently addressing and resolving healthcare-related inquiries.
- Boosted customer retention by promptly handling complaints and providing appropriate solutions.
- Expedited service times with effective triage of incoming calls, directing patients to the correct department or resource.
- Facilitated smooth communication between patients, insurance companies, and medical staff for seamless coordination of care.
- Maintained accurate records of customer interactions, ensuring proper documentation within the company''s database.
- Streamlined appointment scheduling process by utilizing advanced software tools, optimizing time management for both patients and medical professionals.
- Reduced patient wait times while improving satisfaction levels through efficient problem resolution skills tailored to each unique situation.
- Increased first-call resolution rates by carefully listening to customers'' needs and providing accurate information based on their inquiries.
- Ensured compliance with HIPAA regulations when handling sensitive patient information, protecting client privacy at all times.
- Stayed calm under pressure to and successfully dealt with difficult situations.
- Obtained patient's insurance information and determined eligibility for benefits for specific services rendered.
- Followed up with customers about resolved issues to maintain high standards of customer service.
Manager
Lumberjacks Restaurant
05.2014 - 09.2016
- Enhanced customer satisfaction by resolving disputes promptly, maintaining open lines of communication, and ensuring high-quality service delivery.
- Reduced operational costs through comprehensive process improvement initiatives and resource management.
- Developed a strong company culture focused on employee engagement, collaboration, and continuous learning opportunities.
- Mentored junior team members for career advancement, fostering a pipeline of future leaders within the organization.
- Championed diversity and inclusion efforts within the workplace, resulting in an inclusive environment that fostered creativity and innovation among employees from various backgrounds.
- Managed and motivated employees to be productive and engaged in work.
- Maintained professional demeanor by staying calm when addressing unhappy or angry customers.
- Controlled resources and assets for department activities to comply with industry standards and government regulations.
Education
No Degree - Business Administration And Management
San Joaquin Delta College
Stockton, CAHigh School Diploma -
Independence High School
Lodi, CA05.2014
Skills
- Professional Demeanor
- Multitasking
- Payment and Investigation Escalations
- Analytical Thinking
- Prior authorization processing
- Proficient in Microsoft suite, (outlook, excel power point, teams & one note)
- Medical Terminology
- Time management abilities
- Insurance Coverage Verification
- Appointment Scheduling
- Claims adjustment/ Claims Processing
- Data Entry Software
- Customer Service
Timeline
Claims Representative
Blue Shield Of CA
01.2021 - Current
Healthcare Customer Service Representative
Point Quest Pediatrics
02.2016 - 11.2020
Manager
Lumberjacks Restaurant
05.2014 - 09.2016
No Degree - Business Administration And Management
San Joaquin Delta College
High School Diploma -
Independence High School