Dedicated and compassionate Registered Nurse (RN) with a progressive career history in direct patient care and care coordination in a fast-paced environment. Demonstrated ability to remain calm under pressure and skillfully handle difficult patients and high-stress situations. Consistently fosters strong relationships with patients and families through empathetic communication, a respectful attitude, and a commitment to excellent customer service.
● Prevent payment of potentially fraudulent and/or abusive claims utilizing medical expertise, knowledge of CPT/diagnosis.
● Review medical record documentation to identify under coded and up coded services.
● Research on provider data and member data to identify new or additional irregular billing patterns.
● Identify diagnoses and procedures basis CPT and diagnostics codes and medical records supplied by provider.
● Amending and creating simple White Pages and Yellow Pages Print and Online listings. Updating of online information i.e., email address, web link and Ad points
● Follow Account Authorization/Authentication guidelines to ensure the protection of customer information.
● Actively promote products and services and seek to lead generate where opportunities exist
● Promote advertising options with customer and encourage further transactions
● Execute broad range of insurance, financial administration processes or medical claims adjudication
● Process inbound / outbound calls to effectively meet customer needs within established productivity goals and turnaround times
● Follow established guidelines in providing customers accurate information regarding their insurance policies and plans
● Check to ensure that appropriate actions were made to resolve customers' problems
● Executes workflow processes to deliver quality service
● Handles different aspects of transaction processing throughout policy life cycle
● Provides customer service to internal business partners to process customer requests
● Monitors medical condition, through constant communication with patient’s doctor, nurse on duty and other hospital staff who has involvement to healthcare service of covered client and evaluates if appropriate medical treatment and intervention is being delivered.
● Properly conducts case management including, but not limited to concise and timely documentation of all case-related information, following up on all cases on daily basis and reporting to next shift.
● Performs primary triage of all incoming call and direct them appropriately.
Medication Administration