Vonja Richardson
Leavenworth,KS
Summary
Highly-motivated employee with desire to take on new challenges. Strong work ethic, adaptability, and exceptional interpersonal skills. Adept at working effectively unsupervised and quickly mastering new skills.
Overview
16
16
years of professional experience
Work History
Member Experience Specialist Claims Processing
Kaiser Permanente, Colorado
Aurora, Colorado
10.2000 - 02.2017
- Assisted members with inquiries regarding health plans and services.
- Provided guidance on benefits and coverage options for members.
- Managed member accounts using electronic health record systems.
- Educated members on benefits and available resources.
- Resolved member concerns through effective problem-solving techniques.
- Maintained accurate member records in the database system.
- Collaborated with team members to enhance overall member experience.
- Ensured compliance with relevant laws governing membership policies and procedures.
- Managed communication between staff, volunteers, members via email, phone calls, text messages.
- Collaborated with internal teams to ensure smooth operations and seamless experiences for members.
- Greeted members upon arrival, providing assistance with membership applications and other related processes.
- Participated in team meetings to discuss challenges faced by members and brainstorm solutions.
- Provided exceptional customer service to members, addressing inquiries and resolving issues in a timely manner.
- Resolved complaints from customers regarding products or services in a professional manner.
- Enhanced member relationships by providing excellent service during each interaction.
- Answered member questions about products and services.
- Managed customer conflicts and challenging situations by staying calm and accessing internal knowledgebases to develop strategic solutions.
- Presented and explained services and products to meet member needs.
- Engaged in conversation with customers to understand needs, resolve issues and answer product questions.
- Facilitated member inquiries regarding health plans and services.
- Reviewed claims for accuracy and compliance with company policies.
- Processed incoming claims using claims management software.
- Communicated with clients to gather necessary documentation for claims.
- Resolved discrepancies in claims by coordinating with internal teams.
- Maintained detailed records of claim processing activities and communications.
- Trained new team members on claims processing procedures and systems.
- Assisted in developing process improvements for efficient claims handling.
- Collaborated with management to ensure timely claim resolution and customer satisfaction.
- Maintained accurate records of all claim processing activities in a timely manner.
- Resolved discrepancies between provider's billings and insurance contracts.
- Analyzed patient accounts to identify underpayments or overpayments.
- Reviewed and processed medical and dental claims to ensure accuracy of information.
- Monitored aged claims on a regular basis to ensure timely resolution of disputes.
- Reviewed submitted documentation from providers for completeness prior to submitting claims.
- Adhered to HIPAA privacy standards when handling confidential patient information.
- Continuously monitored changes in industry standards related to health care reimbursement practices.
- Investigated, researched and responded to customer inquiries regarding billing issues.
- Attended training sessions to stay current on new policies or procedures for claim processing.
- Provided assistance with preparing documents for appeals process as needed.
- Performed data entry into various systems related to claims processing tasks.
- Worked collaboratively with other departments such as customer service and coding staff.
- Verified eligibility, benefits, authorization requirements for services rendered.
- Verified claim data correctness in preparation for processing.
- Processed claims according to established quality and production standards and made corrections and adjustments to solve problems.
- Addressed customer inquiries to provide information and explanations on coverage and terms, expediting claims.
- Built rapport and trust with injured insureds through effective customer service techniques which involved fair and prompt processing of claims.
- Coordinated benefits with medical insurance plans and Medicare providers.
- Reviewed history records to determine benefit eligibility for services.
- Researched medical claims for validity to resolve discrepancies.
- Collaborated with adjusters and underwriters to resolve complex claim issues.
- Followed up on pending claims and resolved issues delaying processing.
- Adhered to state and federal regulations regarding insurance claims processing.
- Provided training and guidance to new claims processors on department procedures.
- Coordinated with healthcare providers to obtain missing information or clarification on claims.
- Reviewed and processed incoming insurance claims to ensure accuracy and completeness.
- Calculated benefits due based on policy terms and claim information.
- Maintained confidentiality of policyholder information in compliance with HIPAA regulations.
- Determined coverage by examining claim forms and supporting documents.
- Utilized claims processing software to streamline workflow and increase efficiency.
- Processed claims for payment or forwarded to appropriate personnel for further investigation
Education
Some College (No Degree) - Business Administration and Management
Kansas City Business College
Kansas City, MO03-1975
High School Diploma -
Sumner High
Kansas City, KS05-1974
Skills
- Training & Development
- Excellent Communication Skills
- Analytical and critical thinking
- Dependable and responsible
- Front and Backend Resolution
- Customer Service Specialist
- Medicare/Medicaid Knowledge
- Institutional and Professional Claims
- Health Claims Specialist
- Claims Processing
- Lead for 25 representatives
Timeline
Member Experience Specialist Claims Processing
Kaiser Permanente, Colorado
10.2000 - 02.2017
Some College (No Degree) - Business Administration and Management
Kansas City Business College
High School Diploma -
Sumner High