Leslie DeRose
Aliquippa,PA
Summary
I have over 25 years of experience in the medical field. I have been working from home for the last 18 years handling auto and workman's compensation claims and inquiries. I have vast knowledge of ICD 9 and ICD 10 codes as well as the auto and workers compensation state laws and guidelines. Highly-motivated worker with desire to take on new challenges.
Overview
22
22
years of professional experience
Work History
Claims Specialist
Highmark Inc/Independence Blue Cross/Shield
Pittsburgh, PA
10.2018 - Current
- Reviewed and analyzed Auto and Workman's compensation claims to determine validity, completeness, accuracy, and eligibility for payment.
- Processed payments for valid claims according to established procedures, state guidelines and policies.
- Interpreted legal documents related to Auto and Worker's compensation claims processing such as contracts and policy language.
- Collaborated with other departments within the organization to resolve issues related to claims processing.
- Reviewed denied claims for errors or omissions before finalizing decision notices.
- Coordinated with external parties such as lawyers, auto carriers and workman's compensation carriers during investigations.
- Advised management on potential changes needed in policies or procedures based on findings from investigations.
- Facilitated communication between providers, attorneys, adjusters , and other parties involved in a claim.
- Trained new employees and cross trained coworkers in the day to day processes of handling OPL claims and inquires as well as handling of special projects.
- Filled in for Techinal Assistant when she was not available.
Other Party Liability Specialist
Highmark Inc.
Pittsburgh, PA
07.2007 - 10.2018
- Received incoming phone calls from members, providers,auto carriers,workmans compensation carriers and attorneys.
- Made calls to members,providers,auto carriers,workmans compensation carriers and attnorneys to obtain information needed to process medical claims or finalize cases.
- Processed auto and workmans compensation claims
Customer Service Representative
Highmark, Inc.
Camp Hill, PA
10.2002 - 07.2006
- Received incoming calls from Federal Employees and providers.
- Provided excellent customer service to resolve customer complaints in a timely manner.
- Answered customer inquiries and provided accurate information regarding products and services.
- Provided exceptional customer service to ensure customer satisfaction.
- Processed claims for Durable Medical Equipment.
- Tracked orders from start to finish to ensure timely delivery of goods or services.
- Maintained a high level of professionalism when dealing with difficult customers.
- Answered inbound calls, chats and emails to facilitate customer service.
- Called for authorizations for equipment as needed
- Processed facility claims.
Education
GED -
Northwest High School
Justin, TXSkills
- Documentation Review
- Insurance knowledge
- Verbal Communication
- Microsoft Office
- Claims Processing
- Policy Interpretation
- Claims Investigation
- Data Entry
- Claim Amount Calculations
- Eligibility Determination
- Customer Service
- Teamwork and Collaboration
- Goal Setting
- Time Management
- Medical Terminology
- Insurance Coverage Verification
- Problem-Solving
- Documentation skills
- Professionalism
- Excellent Communication
- Adaptability and Flexibility
- Decision-Making
- Attention to Detail
- Understanding of medical terms
Timeline
Claims Specialist
Highmark Inc/Independence Blue Cross/Shield
10.2018 - Current
Other Party Liability Specialist
Highmark Inc.
07.2007 - 10.2018
Customer Service Representative
Highmark, Inc.
10.2002 - 07.2006
GED -
Northwest High School