Lydia X Chavez

• Analyze medical claim issues in accordance with GCHP policies and procedures.
• 
  Properly documented all calls/contacts as required by department standards in a timely, clear and concise manner.
• 
  Addressed provider complaints of medical claims, payments and processing, UM authorizations, member benefits and eligibility, provider contracts, grievances and appeals decisions and provider portal support.
• 
  Responded to phone and email questions and concerns, resolving many issues daily.
• 
  Address provider complaints and provide instruction and oversight.
• 
  Analyze information to assure resolutions are in compliance with all regulatory and contractual requirements.
• 
  Provided guidance to BPO (Business Process Outsource) in auditing claims history for recoveries and adjustments for claims.

• Welcomed members & providers responding to inquiries in a timely manner.
• Answered product and service-related questions effectively.
• Addressed inquiries such as provider billing disputes on behalf of members, benefits & eligibility verification for providers.
• Assisted over 1000 members with refunds, escalation & taking binder & premium payments.
• Ensure that accurate information was provided to providers in a timely manner & with the highest level of customer service.
• Documented interactions with providers & members, including resolution or escalation steps in the system of record for each call, detailing information such as: Caller information; Information related to request/issue; Resolution information or escalation steps.
• Responded to customer inquiries and complaints, providing timely and effective solutions to maintain high service standards.
• Identified needs of customers promptly and efficiently.
• Displayed strong telephone etiquette, effectively handling difficult calls.
• Utilized document management system to organize company files, keeping up-to-date and easily accessible data.
• Set specific goals for projects to measure progress and evaluate end results.
• Monitored operations and reviewed records and metrics to understand company performance.
• Maintained positive working relationship with fellow staff and management.
• Supported the Call Center in meeting State regulatory requirements by handling member & provider inbound calls.
• Executed special projects & ad-hoc assignments as assigned.
• Navigated multiple programs/databases effectively while assisting each caller.
• Possessed proficient knowledge in healthcare product lines, medical terminology & claims process/status.
• Demonstrated strong problem-solving skills when faced with challenging situations or complex inquiries from customers.
• Consistently met daily performance goals set by management team members.

Coordinated with contracting department to resolve payer issues and maintained member & provider service at high priority:

• Use of claim knowledge to conduct research & analyze provider billing errors
• Clearly documented claims research results and root cause of processing errors to be sent for adjudication
• Able to complete tasks individually within the provided timeline or before
• Individually worked on projects during down time to complete, clean up & close open call tracks of other reps as assigned by Supervisor
• Demonstrated rapid multi-tasking skills during high call volumes.

• Worked effectively under pressure and accurately complete tasks within established times.
• Utilized knowledge of medical terminology and related procedure and diagnostic coding (CPT/ICD).
• Conducted premium payment investigations.
• Provided basic information, such as code verification, date of claim payment, and durable medical equipment eligibility.
• Followed up with customers on unresolved issues.
• Reviewed outstanding requests and redistributed workloads to complete projects on time.
• Evaluated financial information provided by claimants in order to process payments quickly and accurately.
• Researched medical records to evaluate claim validity and verify the existence of pre-existing conditions.
• Investigated complex or high-value claims to identify discrepancies and fraud indicators.
• Collaborated with other departments within the organization to resolve issues related to claims processing.
• Assisted with providing appeals status on denied claims.
• Identified trends in rejected claims that could indicate system errors.
• Maintained knowledge of policies and procedures and insurance coverage benefit levels, eligibility systems and verification processes.
• Documented all claim activities in a clear and concise manner.
• Evaluated claims for potential fraud and took appropriate actions.
• Retained strong medical terminology understanding in effort to better comprehend procedures.
• Assisted claimants, providers and clients with problems or questions regarding claims.
• Corresponded with insured or agent to obtain information or inform of account status or changes.
• Maintained up to date knowledge of insurance laws and regulations.