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Novitas Solutions - Credentialist Specialist Resume Example

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Ariana Alexander
Professional Summary
Dedicated insurance professional with more than 7 years of experience investigating and processing claims. Excel in analyzing, interpreting, and negotiating policies and payment solutions. Effectively managed multiple, high priority projects and providing exemplary customer service.

Claims Heading and Inventions Risk Assessment. Mitigation Insurance Verification.

Claims Reports and Documentation.  Policy Interpretation.

Confidential Records Management

Credentialist Specialist / Electronic funds transfer 06/2013 to Present
Novitas Solutions Tallahassee, FL
Maintain a working knowledge of and follow Patient Financial Services and clinic/hospital policies and procedures.Process patient encounters and claims on a daily basis. Process charge review work queue and claim edit work queue on a daily basis.Prepare claims accurately by adhering to all CMS and specific insurance guidelines.Review, validate, update and correct, if necessary, demographic and insurance information on specific claims and on patient accounts. PHI and coverage information for the encounter posted should be reviewed.Process charge corrections promptly and accurately within specified time frames.Communicate with coworkers, management and providers when concerns are found that could jeopardize accuracy of claims being filed, particularly patterns of errors or inaccuracies for all files and documentation.Post hospital charges for assigned divisions using methods to ensure accuracy, including daily balancing of hash totals and adding machine tapes.Interact with coworkers and clinic personnel in a productive, courteous and cooperative manner.Work as an integral member of the team to assist with duties necessary to cover for team members when they are out.Maintain working knowledge of the authorization and pre-certification processes.Accurately assign diagnosis codes and/or procedure codes to reflect the medical necessity of services provided from the medical documentation.
Eligibility Coordinator 01/2011 to 06/2013
Xerox ACS Florida Healthy Kids Tallahassee, FL
Manage assigning caseload. Evaluate eligibility by collecting information from clients via mail or phone. Follow up and monitor missing information for eligibility determination. Proactively take all necessary action to move application forwards. Developed and maintain professional effective relationship with internal and external customers. Maintain accurate and detailed data on case status requirements. Kept clients informed by communicating case progress. Demonstrate a serous commitment to accuracy and quality while meeting goals and deadlines. Learn and maintain technical program policy proficiency in Florida Healthy Kids rules and guidelines and other related program policies. Reviewed financial records, such as income statements, prior tax return and profit and loss statements. Verify and examine tax documents to obtain additional information from clients regarding taxable income, deductible expense and allowances.
Outcomes�  Completed more than 2,500 applications throughout tenure. Provided optimum service to negotiate fair settlements and identify fraudulent accounts.�  Selected by supervisor to assist with Medicaid closures, resolve complex processing issues, participate in quality control audits, and monitor application status updates. Maintained a superior quality rating of 94% in file handling and accounts resolution from 2011 to present, exceeding the 85% department goal.
Registration Patient Coordinator 04/2008 to 01/2011
Capital Regional Medical Center Tallahassee, FL
Interview patients at workstation or at bedside to obtain all necessary account information. Bed-side registration performed utilizing carts/computers on wheels Ensure charts are completed and accurate Verify all insurance and obtain pre-certification/authorization Calculate and collect patient liable amounts Ensure that all necessary signatures are obtained for treatments Answer any questions and explains policies clearly Process patient charts according to paperwork flow needs and established productivity standards Welcome patient and family members in a professional manner. Contact the nursing staff for emergency medical needs and answer patient and visitor questions Interview incoming patients, his/her relatives, or other responsible individuals to obtain identifying and biographical information with insurance and financial information Assign I-plans accurately and research Patient Visit History to comply with the Medicare 72 hour rule Search MPI completely and assign the correct medical code number. Notify Medical Records for any duplicate unit numbers Verify insurance benefits and determines pre-certification status. If pre-certification is needed, call the insurance precert department and initiate review or verify authorization number provided by scheduling staff. Enter all information and authorization numbers into the registration system. Secure all signatures necessary for treatments, release of medical information, assign..
Assistant Manager 08/2005 to 12/2010
MaxRave BCBG Tallahassee, FL
Meet personal and store sales goal. Assist in the tracking, monitoring, and communication of business results. Ensure an elevated level of sales and service is practiced by all associates; lead by example.
Continue to develop personal sales techniques and assist in the development of associates' sales techniques to maximize sales.
Ensure all sales related policies and procedures are maintained. Demonstrate an in-depth knowledge of the merchandise, and develop product knowledge among selling staff.
Maintain a keen interest in the fashion industry and market trends. Ensure all associates provide the highest level of customer service. Build and maintain repeat clientele by utilizing personal client book and assisting staff with utilizing their client books. Resolve all client problems and complaints quickly and effectively. Assist sales associates with various customer service issues (i.e. dissatisfied customers, returns, defective merchandise).
Collaborate with store manager in areas of risk management, physical security, store cash controls, and inventory management. Support and assist in staff training in all areas of appropriate register usage and maintenance. Understand and properly execute all management register functions. Participate in inventories. Understand and execute cash control procedures including:Assist in the implementation and maintenance of all merchandizing/ visual directives
High School Diploma: Mar 2001 Fernandina Beach High School - Fernandina Beach, FL
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Resume Details

This is a real resume for a Credentialist Specialist in Yulee, Florida with experience working for such companies as Novitas Solutions, Xerox Acs Florida Healthy Kids, Capital Regional Medical Center. This is one of the hundreds of Credentialist Specialist resumes available on our site for free. Use these resumes as templates to get help creating the best Credentialist Specialist resume.

Previous Companies:

  • Novitas Solutions
  • Xerox ACS Florida Healthy Kids
  • Capital Regional Medical Center

Previous Job Positions:

  • Credentialist Specialist
  • Electronic funds transfer
  • Eligibility Coordinator
  • Registration Patient Coordinator
  • Assistant Manager


  • Fernandina Beach High School

Level of Education:

  • High School Diploma

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Credentialist Specia...

Yulee, Florida

Companies Worked For:

Novitas Solutions, Xerox ACS Florida Healthy Kids,...

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