Melva Victorian

• Encouraged independence while providing assistance when needed.
• Ensured that client safety was maintained through regular home visits.
• Assisted with personal care tasks such as bathing, dressing, toileting, and grooming.
• Kept detailed records related to client interactions, services provided, and medications administered for documentation purposes.
• Coordinated with other healthcare professionals, including nurses, doctors, dieticians, in order to ensure comprehensive care.
• Participated in team meetings and training sessions to stay up-to-date on best practices for caring for elderly individuals.
• Collaborated with social workers and case managers in order to develop appropriate service plans.

• Prepared reports summarizing utilization patterns, outcomes, and quality measures.
• Analyzed data to identify areas where improvement initiatives could be implemented.
• Monitored compliance with regulatory requirements related to utilization management activities.
• Completes denial letters for services denied by Medical Director.
• Generates and prints denial letters for mailing.
• Provides feedback to ensure denials are handled according to CMS standards. Collaborates with other departments to produce letters for services denied in their respective units.
• Identifies opportunities to enhance workflow and offers solutions. Answers and routes incoming calls from providers, medical groups, and others verifying referral status.
• Developed and implemented utilization management policies and procedures.
• Reviewed claims for accuracy prior to submission for payment processing.
• Reviewed appeals from members or providers regarding denied services or treatments.
• Analyzed large datasets with statistical methods and software programs.

• Assisting providers with billing issues, claims, appeals, and payments.
• Contacting providers, claimants, and policyholders’ day to day.
• Manually processing bills and also scanning the bills into the system.
• Assisting with the medical coding of bills, HIPAA guidelines and PHI.
• Acting as a liaison for the policyholder, provider and the claim rep.
• Following the policy and procedures for workers comp insurance and Medicare guidelines.
• Providing excellent customer service to the customers.
• Handling the customer’s issues in a timely manner.
• Educating the providers on how to bill their claims and the timely filing process.
• Case Management provider referral, discharge planning coordination and follow up of workers compensation injury claims.
• Educate providers, members and community resources on available support services, policies and procedures related to referrals, authorizations, claims submission, web site usage and related topics.
• Analyzing written reports, such as medical records and legal documentation.
• Experience with disputed and litigation worker’s compensation claims.
• Strong written and oral communication skills, analytical, investigative, and negotiation skills.
• Advanced knowledge of coverage, liability, and complex claims handling procedures. Full working knowledge of claims operations and procedures.
• Maintains knowledge of required lines of business, changes to applicable company policies/procedures, recent laws, and regulations, HCPCS coding, ICD-9 codes, medical terminology and related computer systems to ensure information is current and accurate when providing service to members.
• Provider credentialing and provider contracting.
• Utilized CRM software to track customer interactions, sales, and progress towards targets.
• Compiled and analyzed sales data to identify trends and opportunities for growth.
• Coordinated with logistics and supply chain teams to ensure timely delivery of products.

• Assisting providers with claims, denials, and billing instructions.
• Contacting providers/billers daily to reconcile old accounts.
• Account reconciliation and insurance guideline support of Medicaid service providers.
• Documenting billing information in regards to patient, insurance, and patients’ employer encounters.
• Researching and appealing rejected/denied claims.
• Maintained accurate records of all communications with providers including emails, letters, phone calls.
• Negotiated terms for new contracts with providers while ensuring that company policies were adhered to.
• Organized timely and accurate referrals to help patients obtain health care services and access available resources.

▪ Liaison between patients, facility staff, and the Central Billing Office.

▪ Answering calls in a timely manner and resolving all provider issues.

▪ Explaining policy, procedure and guidelines for Medicaid implemented by Department of Health and Human Services.

▪ Educating and counseling patients regarding insurance issues such as ramifications of changing coverage, electing COBRA, Disability benefits, financial assistance programs, etc.

▪ Advocating for patients' insurance rights by contacting patients’ employers, disability insurance, Medicaid, and family members.

▪ Providing creative, professional, and timely resolutions to patient and/or costumer complaints and concern calls, resulting in the retention of countless patients and clients.

▪ Evaluates medical records from facilities and/or Office of Behavioral Health (OBH) to verify all applicants are suffering with a serious mental illness (SMI) and/or intellectual disability.

▪ Completes the preadmission screening and resident review (PASRR) process to ensure individuals are not inappropriately placed in nursing homes for long term care.

▪ Community outreach and Case Management intervention referral, discharge planning coordination and follow up.

▪ Provider credentialing, provider contracts and case management.

• Attended training sessions to stay abreast of changes in industry regulations related to collections practices.
• Handled incoming calls from customers regarding account status, billing inquiries, payment arrangements.
• Analyzed customer creditworthiness, financial condition, and account history to determine appropriate collection action.

• Compiled and maintained records of provider contracts, claims processing issues, authorizations, and other related matters.
• Reviewed current trends in reimbursement practices, payer policies, and healthcare regulations to inform decisions related to provider networks.
• Tracked changes in provider enrollment status and updated internal systems accordingly.
• Assisted customers with claims processing and managing medical records.
• Served as an account’s receivables/customer service representative.
• Responded to and resolved difficult customer service issues.
• Quickly and effectively solve customer challenges via phone and via e-mail
• Maintained quality control/satisfaction records, constantly seeking new ways to improve customer service.
• Community outreach and Case Management intervention referral, discharge planning coordination and follow up.
• Assisting members with scheduling appointments and providing them with healthcare assessments, transportation assistance if needed, PCP or specialist selection.
• Provider contracting and provider credentialing.
• Coordinated provider orientations to ensure a comprehensive understanding of company policies and procedures.
• Created reports detailing key performance indicators used for tracking progress toward goals set by management.

• Analyzed competitor pricing strategies to stay competitive in the marketplace.
• Collaborated with other departments to ensure a seamless customer service experience.
• Actively sought out new sales opportunities by engaging existing customers in conversations about additional products or services they may be interested in purchasing.
• Worked for various companies assisting with customer service.
• Also worked for the Road Home Program by new applications and assisted on status of old applications.
• Also worked for United Healthcare as a remote agent from home.
• Responsible for the most complex customer service issues as a result of exceptional ability to promptly resolve concerns and satisfy customers.
• Answered customer inquiries via telephone, email and social media platforms.
• Compiled weekly and monthly performance metrics related to customer relations activities.
• Analyzed customer feedback data to identify areas of improvement in the customer experience.
• Mentored new employees on procedures and policies to maximize team performance.

• Created loyalty programs to reward repeat customers for their patronage.
• Provided product information, pricing and availability to customers.
• Collaborated with other departments to ensure a seamless customer service experience.
• Assisted with billing and relocation of accounts.
• Worked onsite and as a remote agent.
• Provided technical support to customers via phone.
• Ability to train, motivate, and supervise customer service employees.
• Analyzed customer feedback data to identify areas of improvement in the customer experience.
• Processed payments from customers using various payment methods including cash, credit cards, checks.
• Analyzed competitor pricing strategies to stay competitive in the marketplace.
• Developed customized sales plans for individual customers based on their needs.
• Monitored inventory levels of products regularly and placed orders as needed.
• Provided detailed explanations of product features and benefits.
• Acknowledged with the “Total Quality Customer Service Professional” award.