Tajmah Thompson
Zebulon,NC
Summary
Driven to promote customer satisfaction through personalized and knowledgeable support for different requirements. Self-directed in investigating and resolving inquiries. Demonstrated skills in meeting and surpassing productivity targets. 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
15
15
years of professional experience
Work History
Provider Coordinator
AmeriHealth Caritas Family of Companies
09.2022 - Current
- Assisted with the preparation of presentations for senior management meetings.
- Facilitated communication between different departments in order to resolve issues quickly.
- Trained employees on best practices and protocols while managing teams to maintain optimal productivity.
- Analyzed customer feedback surveys in order to identify opportunities for improvement.
- Interpreted and explained work procedures and policies to brief staff.
- Booked hotel rooms, car rentals, and flights for company trips and conferences.
- Resolved provider complaints or answered providers' questions.
- Researched and prepared reports required by management or governmental agencies.
- Maintained records of providers needs and preferences.
- Managed day-to-day operations of the department including scheduling tasks and assigning duties.
Provider Services Representative
AmeriHealth Caritas Family of Companies
09.2021 - Current
- Trained employees on best practices and protocols while managing teams to maintain optimal productivity.
- Verified accuracy of submitted documentation prior to processing claims or services rendered.
- Delivered exceptional customer service to clients by communicating information and actively listening to concerns.
- Reviewed and processed provider claims for medical services rendered to ensure accuracy of payments.
- Adhered to federal regulations and laws governing the processing of health care claims.
- Identified trends in denied claims and recommended process improvements.
- Worked closely with providers to resolve pending claim issues and disputes.
- Participated in training sessions related to coding changes, billing system updates.
Claims Resolution Specialist II
MPF Federal
11.2020 - 06.2021
- Researched and reviewed information to determine validity of insurance claims and contacted companies and customers about decisions.
- Performed quality assurance reviews on newly submitted claims for completeness and accuracy.
- Adhered to established workflow processes and timelines in order to meet performance goals.
- Collaborated with other departments to obtain additional information needed for claim resolution.
- Analyzed information gathered by investigations and reported findings and recommendations.
- Input claim information and payments into company database.
- Reviewed, evaluated and processed incoming claims to determine eligibility for coverage based on policy provisions.
- Researched complex insurance issues to resolve discrepancies in claims data.
- Resolved claims by approving or denying documentation, calculating benefits due and determining compensation settlement.
Provider Database Coordinator
WellCare Comprehensive Health Management
08.2019 - 11.2020
- Worked to insure CAQH is updated with the correct provider credentials
- Worked with delegated providers and IPAs to process new provider load requests along with any updates or changes within the group via a roster methodology.
- Supported the provider relations representatives in resolving claims and payment issues.
- Verified provider Medicaid credentials via NCTRACKS.
- Create New LOB, LOA contracts, Updated and termed providers as needed for managed care plans. Performed outreach to office managers and or credential to obtain needed provider or facility information via email or phone
Claims Analyst
Spectra Force Technologies Inc
01.2018 - 05.2019
- Reviewed policies to determine appropriate levels of coverage and assist with approval or denial decisions.
- Gathered proper documentation and data to prepare claims for submission.
- Cultivated strong relationships to maintain provider network knowledge and implement corrective actions for ongoing issues.
- Utilized Power MHS and Core Plus systems for obtaining benefit and claims information. Documented.
- Documented correspondence using the system Facets and Service First & Reviewed ICD 9 and 10 CPT codes and HCPS Codes and diagnosis with providers and advised providers how to fill out complex claim forms like CMS 1500 and UBO4 claim forms.
- Responded to provider / hospital inquiries concerning contract and claims issues and Analyzed Explanation of benefit (EOB) forms to ensure payments were paid to providers.
Patient Account Coordinator
College Foundation of North Carolina
05.2016 - 01.2017
- Contacted customers with delinquent accounts to solicit payment.
- Investigated billing discrepancies and implemented effective solutions to resolve concerns and prevent future problems.
- Worked closely with delinquent account holders to collect and reconcile accounts through approved channels.
- Located new addresses of delinquent customers through research, contacting credit bureaus or by questioning neighbors.
- Encouraged customers to pay due amounts on credit accounts, claims or overdrawn checks.
- Maintained accurate records of all activities within the department's database system.
- Monitored overdue accounts using automated information systems.
- Processed credit card payments and submitted adjustments to patients' accounts as needed.
Medical Claims Processor
GlaxoSmithKline Pharmaceuticals
05.2011 - 04.2016
- Stayed current on HIPAA regulations, benefits claim processing, medical terminology, and other procedures.
- Collaborated with fellow team members to manage large volume of claims.
- Administered standard contract benefits to process pending claims for dental benefits.
- Analyzed physician's reports, hospital records, laboratory results, operative reports, diagnostic tests. to assess medical necessity of services rendered.
- Identified potential fraud cases based on analysis of submitted claims data and escalated accordingly.
- Calculated payments due based on allowed charges compared to billed charges according to contract terms with payers, insurers, third parties.
- Investigated discrepancies in medical billing information such as incorrect codes or amounts due.
- Processed claims for payment or forwarded to appropriate personnel for further investigation
- Called insurance companies to ascertain pertinent information regarding policies and payment benefits for patients.
- Organized information by using spreadsheets, databases or word processing applications.
Customer Service Representative Team Lead
Xerox, ACS
07.2009 - 06.2011
- Coordinated schedule to maintain appropriate staff coverage.
- Prepared and evaluated CRM reports to identify problems and areas for improvement.
- Adjusted bills and refunded money to resolve customers' service or billing complaints.
- Trained staff to provide excellent customer service to challenging customers.
- Assisted with the hiring process of new Customer Service Representatives.
- Increased customer satisfaction ratings 80% by effectively answering questions, suggesting effective solutions and resolving issues quickly.
- Acted as liaison between management, customers and other stakeholders when needed.
- Performed quality assurance audits of calls handled by representatives.
Education
High School Diploma -
Phillips High School
Raleigh, NC06-2009
Skills
- Data Entry
- Schedule Management
- MS Office
- Data Analysis
- Claims Investigation
- Decision-Making
- Time Management
- Team Collaboration
Timeline
Provider Coordinator
AmeriHealth Caritas Family of Companies
09.2022 - Current
Provider Services Representative
AmeriHealth Caritas Family of Companies
09.2021 - Current
Claims Resolution Specialist II
MPF Federal
11.2020 - 06.2021
Provider Database Coordinator
WellCare Comprehensive Health Management
08.2019 - 11.2020
Claims Analyst
Spectra Force Technologies Inc
01.2018 - 05.2019
Patient Account Coordinator
College Foundation of North Carolina
05.2016 - 01.2017
Medical Claims Processor
GlaxoSmithKline Pharmaceuticals
05.2011 - 04.2016
Customer Service Representative Team Lead
Xerox, ACS
07.2009 - 06.2011
High School Diploma -
Phillips High School
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