Martika Nelson
Garland,TX
Summary
Resourceful Specialist offering expertise in problem-solving, data analysis and customer service. Adept at quickly learning new technologies and processes for driving success. Proven track record of successfully managing multiple projects and developing innovative solutions.
Overview
3
3
years of professional experience
Work History
AR Specialist II
Dallas Endoscopy Center
06.2022 - Current
- Current position held is a collector with a task of insurance verification for entities such as Medicare
- Medicaid and commercial insurance companies
- Daily duties include but not limited to:
- Conducting research on claims processing which includes following guidelines per the insurance company , member eligibility , insurance deadlines for appeals / timely filing And submitting any documentation / medical records upon request
- Insurance outreach
- Collecting on old and current accounts
- Working with medical coders to ensure no coding errors with the procedure and diagnosis codes
- Prepared insurance claim forms or related documents and reviewed for completeness.
- Carried out administrative tasks by communicating with clients, distributing mail, and scanning documents.
- Processing refunds (patient/insurance)
- Followed all company policies and procedures to deliver quality work.
- Analyzed marketing data and trends to identify opportunities for improvement.
- Understood requirements for disputes, gathered evidence to support claims and prepared customer cases to handle appeals.
- Calculated adjustments, premiums and refunds.
- Posted payments to accounts and maintained records.
Claim Specialist
Aetna, a CVS Health Company
01.2022 - 06.2022
- Reviews and adjudicates routine claims in accordance with claim processing guidelines
- Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment measures to assist in the claim adjudication process
- Proofs claim or referral submission to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis and pre-coding requirements
- Escalated files with significant indemnity exposure to supervisor for further investigation.
- Collaborated with legal counsel to make organizational claims decisions aligning with governing laws.
- Understood requirements for disputes, gathered evidence to support claims and prepared customer cases to handle appeals.
- Provided advice to customers regarding claims, rights and insurance processes to prevent disputes.
- Maintained strong knowledge of basic medical terminology to better understand services and procedures.
- Checked documentation for accuracy and validity on updated systems.
- Made contact with insurance carriers to discuss policies and individual patient benefits.
Insurance Verification Specialist
Walgreens Boots Alliance
11.2020 - 05.2021
- I am responsible for verifying patient eligibility, coordinating benefits, running test claims, and determining patient coverage/responsibility for services including, but not limited to, major medical insurance benefits (including Medicare), complex insurance plans, and high volume PBM plans
- Process and work with J-Codes, diagnosis codes, route of administration, place of service, IPA claims, Medicare
- B & D billing, Major Medical, and PBM
- Job Responsibilities:
- Utilizes all available resources to obtain and enter insurance coverage information for ordered services; Verifies patient insurance coverage and completes a full Medical Verification of medications, administration supplies, and related pharmacy services through proper investigation into either major medical benefits (including Medicare) or pharmacy benefits; Facilitates and completes the prior authorization process with insurance companies and practitioner offices
- Facilitates pharmacy and/or major medical claims with insurance companies and practitioner offices;
- Investigates and facilitates prior authorization and any other claim rejections
- Notifies patients, physicians, practitioners, and/or clinics of any financial responsibility of services provided and requested services that are not provided by the facility
- Communicates with other departments and senior managers as necessary to facilitate urgent needs;
- Places outbound calls to patients or physicians’ offices to obtain additional information needed to process requests; Manages inbound calls on the insurance line from patients, clients, physicians, practitioners, and clinics regarding inquiries about services provided, financial responsibility, and insurance coverage
- Complied with HIPAA guidelines and regulations for confidential patient data.
- Assisted patients with understanding personalized insurance coverage and benefits.
- Assured timely verification of insurance benefits prior to patient procedures or appointments.
- Managed high-volume insurance verifications within pressured timeframes for productive medical operations.
- Achieved insurance pre-authorizations to enable timely patient procedures.
Education
Medical office specialist in Medical Assisting - Medical Assisting
Richland Community College
Garland, TX07.2010
High School Diploma -
Naaman Forest High School
Garland, TX06.2009
Skills
- Team Performance Improvement
- Personalized Customer Service
- Accounts Payable and Accounts Receivable
- Inbound Phone Calls
- Clerical Support
- Claims
- Office Support
- Electronic Authorization Processing
Additional Information
- Willing to relocate to:, Garland, TX - Plano, TX - Remote Authorized to work in the US for any employer
Timeline
AR Specialist II
Dallas Endoscopy Center
06.2022 - Current
Claim Specialist
Aetna, a CVS Health Company
01.2022 - 06.2022
Insurance Verification Specialist
Walgreens Boots Alliance
11.2020 - 05.2021
Medical office specialist in Medical Assisting - Medical Assisting
Richland Community College
High School Diploma -
Naaman Forest High School
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