Mercedes Burton
Jacksonville,Florida
Summary
Seeking a challenging role within a dynamic organization where my experience, education, and skills can contribute to achieving and surpassing corporate objectives. As an Insurance Verification Specialist, I bring a strong foundation in insurance processes and claims procedures, coupled with exceptional attention to detail and time management capabilities. With a background in verifying benefits and generating accurate patient documentation, I am committed to ongoing learning and adaptation to improve my skills. My experience as a team player with a strong knowledge of medical terms and experience working with diverse personalities makes me an excellent fit for any organization seeking a knowledgeable and adaptable Insurance Verification Specialist.
Overview
6
6
years of professional experience
Work History
Claims Processor
Aetna, a CVS Health Company
02.2022 - Current
- Acts as a subject matter expert by providing training, coaching, or responding to complex issues
- May handle customer service inquiries and problems
- Reviews respecified claims or claims that exceed specialist adjudication authority or processing expertise
- Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process
- Handles phone and written inquiries related to requests for pre-approvals preauthorization’s, reconsiderations, or appeals
- Ensures all compliance requirements are satisfied and that all payments are made against company practices and procedures
- Identifies and reports possible claim overpayments, underpayments and any other irregularities
- Performs claim rework calculations.
Digital Support Specialist
Citi - Jacksonville, FL
06.2021 - Current
- Assists with resolving supervisor-escalated customer inquiries related to account level information, and provides technical assistance as required
- Supports internal and external customers
- Tracks and reports data for management action
- Solves moderately complex problems, time sensitive inquiries, and multi-task in high-volume situations
- Identifies and escalates issues to appropriate sources
- Works under general supervision and established procedures
- May support a range of products/services
- Applies detailed knowledge of a wide range of specialized administrative/technical skills; and most of the impact is related to the accuracy of tasks performed
- Understands how duties relate/integrate with others in the team/unit
- Appropriately assess risk when business decisions are made, demonstrating particular consideration for the firm's reputation and safeguarding Citigroup, its clients and assets, by driving compliance with applicable laws, rules and regulations, adhering to Policy, applying sound ethical judgment regarding personal behavior, conduct and business practices, and escalating, managing and reporting control issues with transparency.
Patient Access Representative
Southeast Orthopedic Specialists
06.2018 - 06.2021
- Answer all incoming calls in a timely and efficient manner
- Schedule/reschedule patient appointments with correct appointment type
- Mail out new patient information packets via email or postal service
- Take messages and task to the appropriate staff member
- Take consults from doctors’ offices and hospitals; text, email and/or fax to the appropriate providers
- File faxes and batches from ICS
- Retrieve, and appropriately handle, voice messages for the medical assistants
- Handle correspondence, faxes and disability paperwork that needs to be sorted and scanned into the system
- Mail “Thank You” letters to referring physicians
- Additional support/tasks as assigned.
Education
Samuel W.High School
Jacksonville, FLSkills
- Claims review
- Accuracy and Precision
- Transactions reconciliation
- Claims
- Claims Processing Software
- Policy Interpretation
- Regulatory Compliance
- Professionalism and Ethics
- Technical aptitude
- Insurance Regulations Understanding
- Data entry proficiency
- Medical terminology knowledge
- Critical Evaluation
- Attention to Detail
Timeline
Claims Processor
Aetna, a CVS Health Company
02.2022 - Current
Digital Support Specialist
Citi - Jacksonville, FL
06.2021 - Current
Patient Access Representative
Southeast Orthopedic Specialists
06.2018 - 06.2021
Samuel W.High School