Greetings! I am Chelsey

CONCENTRIX
(QUALITY ASSURANCE AUDITOR & HEALTHCARE CLAIMS ASSOCIATE)

Quality Assurance Auditor :
• Audit internal calls ensuring if quality standards are met most important of which are HIPAA guidelines.
• Ensuring at the end of the call, that all the issues are addressed and no negative financial impact and incorrect protocols were done by the healthcare associate.
• Audit chat interaction initiated by the providers on the CRM tool (Live Person) ensuring HIPAA is satisfied
• Tabulating audited calls thru excel sheets and thru internal tool. Managing email for audit disputes, possessing deep knowledge and understanding if the internal inaccuracy can be upheld or overturned. Accepting supervisory calls for un-escalated provider issues.
• Assisting new employees on the last day of their training and performing mock calls to endorse them to the actual call task.
• Creating meetings via outlook and hosting calibration via teams for accuracy reports of the department.
• Endorsing and providing workflows for the department to adapt to their call flow.

HEALTHCARE CLAIMS ASSOCIATE:
• Initiating outbound calls to medical professionals for insurance updates. Accepting inbound calls for claims status and inquiry.
• Escalating appeals and reviewing claim denials.
• Analyzing explanation of benefits
• Reviewing medical records from EMR/EHR tools.
• Verifying provider participation status.
• Checking payment status and issuing unissued checks, virtual cards, and EFT.
• Confirming if W9 forms are updated
• Sending unpaid service codes for adjustment (ex; office visits service, covid related service)
• Ensuring no loopholes for unpaid claims
• Reaching out to state plans and other insurance plans.
• Dispatching invalid rejected claims for reprocessing.
• Pricing service codes based on provider’s contract.