Vanessa Moore
Greenville,NC
Summary
Knowledgeable and dedicated customer service professional with extensive experience in the Healthcare industry. Solid team player with outgoing, positive demeanor and proven skills in establishing rapport with clients. Motivated to maintain customer satisfaction and contribute to company success. Specialize in quality, speed and process optimization. Articulate, energetic and results-oriented with exemplary passion for developing relationships, cultivating partnerships and growing businesses. Strong leader and problem-solver dedicated to streamlining operations to decrease costs and promote organizational efficiency. Uses independent decision-making skills and sound judgment to positively impact company success.
Overview
14
14
years of professional experience
Work History
Provider Claims Services Representative
AmeriHealth Caritas Family Of Companies
11.2022 - 02.2023
- Delivered exceptional customer service to every customer by leveraging extensive knowledge of products and services and creating welcoming, positive experiences.
- Investigated and resolved customer inquiries and complaints quickly.
- Responded proactively and positively to rapid change.
- Met customer call guidelines for service levels, handle time and productivity of 20 to 35 calls per day.
- Educated customers about billing, payment processing and support policies and procedures.
- Effective liaison between customers and internal departments.
- Paid or denied medical claims based upon established claims processing criteria.
- Used administrative guidelines as resource or to answer questions when processing medical claims.
- Reported policy changes and company conditions affecting customer satisfaction.
- Submitted electronic/paper claims documentation for timely filing.
- Maintained knowledge of benefits claim processing, claims principles, medical terminology and procedures and HIPAA regulations.
Utilization Management Technician
AmeriHealth Caritas Family Of Companies
04.2013 - 11.2022
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Performed prior authorization review of services requiring notification.
- Performed admission reviews and discharge planning according to DRG contracts between managed care plans and treating facilities.
- Supervised and maintained all utilization review documentation.
- Submitted cases to Medical Director, Prior Auth, DME & transplant nurses for criteria failures and helped facilitate resolutions and approvals.
- Served as subject matter resource, providing information related to Prior Authorizations, Claims & IP/OP Admissions.
Medical Assistant
Wayne Medical Arts
10.2011 - 04.2013
- Sanitized, restocked and organized exam rooms and medical equipment.
- Obtained client medical history, medication information, symptoms and allergies.
- Directed patients to exam rooms, fielded questions and prepared for physician examinations.
- Collected and documented patient medical information such as blood pressure and weight.
- Performed clerical duties, such as word processing, data entry, answering phones and filing.
- Documented vital signs and health history for patients in clinic and hospital environments.
- Called and faxed pharmacies to submit prescriptions and refills.
- Scheduled appointments, registered patients and distributed sample pharmaceuticals as prescribed.
- Assisted with routine checks and diagnostic testing by collecting and processing specimens.
- Kept medical supplies in sufficient stock by monitoring levels and submitting replenishment orders before depleted.
- Tested and recorded blood glucose levels.
- Gathered forms and copied insurance cards to collect patient information for billing and insurance filing.
- Scheduled appointments, registered patients, and distributed sample pharmaceuticals as prescribed
Certified Nursing Assistant
Philadelphia Nursing Home
08.2009 - 11.2011
- Answered call lights and supported patient comfort and safety by adjusting bed rails and equipment.
- Promoted good oral and personal hygiene by aiding patients with shaving, bathing and teeth brushing.
- Checked patient vitals such as temperature, blood pressure and blood sugar levels.
- Assisted with feeding and monitored intake to help patients achieve nutritional objectives.
- Cared for residents in assisted living facility and delivered high-quality support to meet needs.
- Delivered individualized patient care to 4-6 patients daily by recording vital signs, documenting observations, administering treatments and evaluating patient needs.
- Evaluated patients to identify and address wounds, behavioral concerns and medically relevant symptoms.
- Cared for clients with diagnoses such as respiratory failure, diabetes, Parkinson's disease and muscular dystrophy.
- Supported ambulation and physical therapy needs by conducting planned exercise routines.
- Conferred with multidisciplinary healthcare team to help effectively manage patient conditions with regular testing and vitals assessments.
- Offered immediate assistance in emergency and routine paging situations to evaluate needs and deliver care.
Education
BBA - Healthcare Administration
Western Governors University
Salt Lake City, UT08.2024
Associate of Applied Science - Medical Assisting
Pennsylvania Institute of Technology
Media, PA05.2012
CNA Certification - Certified Nursing Assistant
Leahy Caregivers
Philadelphia, PA08.2009
High School Diploma -
Parkway Northwest
Philadelphia, PA06.2004
Skills
- Client Relationships
- Health Insurance Industry Knowledge
- Determine Medical Necessity
- ICD-10 Coding
- Microsoft Office
- Electronic Claims Processing
- Knowledge of HIPAA Regulations
- Medical Terminology
- Customer Service
- Direct Patient Care
- Patient Data Management Systems
- Benefits Guidelines & Verification
Timeline
Provider Claims Services Representative
AmeriHealth Caritas Family Of Companies
11.2022 - 02.2023
Utilization Management Technician
AmeriHealth Caritas Family Of Companies
04.2013 - 11.2022
Medical Assistant
Wayne Medical Arts
10.2011 - 04.2013
Certified Nursing Assistant
Philadelphia Nursing Home
08.2009 - 11.2011
BBA - Healthcare Administration
Western Governors University
Associate of Applied Science - Medical Assisting
Pennsylvania Institute of Technology
CNA Certification - Certified Nursing Assistant
Leahy Caregivers
High School Diploma -
Parkway Northwest
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