Dana Gaines
Modesto,CA
Summary
Results-driven healthcare billing professional with strong attention to detail and proven ability to resolve discrepancies and negotiate with insurance providers to maximize revenue.
Overview
4
4
years of professional experience
Work History
MEMBER SERVICES COORDINATOR
Blue Shield of CA
07.2021 - Current
- Assist with claims processing, claims adjustments, and modifications to ensure prompt payment for member claims
- Reviewed coding requirements and updated codes as needed for prior authorizations
- Handled customer inquiries and complaints efficiently in a fast-paced environment
- Research denials
- Process prior authorizations
- Utilized CRM software to track and manage customer interactions
- Achieved a customer satisfaction score of 95% through effective problem resolution
- Provided exceptional customer service by addressing inquiries and resolving issues promptly
- Trained new staff on customer service best practices and company policies
CUSTOMER SERVICE REP
H&R Block
12.2020 - 06.2021
- Answer incoming calls and route to correct department
- Greet customers
- Filed tax paperwork
- Appointment Scheduling
- Assisted tax preparers with ensuring all paperwork was attached and loaded into the system
UM Coordinator
AllCare IPA
- Entered data, generated reports, and produced tracking documents.
- Reviewed medical documentation to ensure correct CPT and ICD Coding
- Reviewed insurance processing
- Researching and writing insurance denial letters for prior authorizations and claims
- Managed project timelines for successful completion, ensuring milestones were met and deadlines were adhered to.
- Streamlined communication process between nursing staff and case managers, reducing any delays in patient care plans.
- Maintained accurate documentation of all reviews, appeals, and decisions in line with organizational standards and requirements.
- Collaborated closely with physicians to identify appropriate levels of care based on medical necessity criteria during admissions process.
- Scheduled surgeries, managed pre-certifications and verified insurance coverage.
Education
Associate of Arts - Registered Health Information Technology
Shasta Community College
Redding, CA05.2026
Skills
- Records Management
- Answering phones 16 lines
- Claims processing
- Data Entry
- Insurance Management
- Writing medical denial letters
- Prior Authorization
- Written and Verbal Correspondence
- Light Medical Coding and Filing
- Customer Service
- Problem Solving
- Typing 40 wpm
- Call center experience
- Data entry
- Active listening
- Critical thinking
Timeline
MEMBER SERVICES COORDINATOR
Blue Shield of CA
07.2021 - Current
CUSTOMER SERVICE REP
H&R Block
12.2020 - 06.2021
UM Coordinator
AllCare IPA
Associate of Arts - Registered Health Information Technology
Shasta Community College
Similar Profiles
Hemraj PandeyHemraj Pandey
QA Analyst at Blue Shield of CA -InfosysQA Analyst at Blue Shield of CA -Infosys
WENDY GARCIAWENDY GARCIA
Care Service Coordinator, Specialist at Blue Shield of CACare Service Coordinator, Specialist at Blue Shield of CA
Diamond BaileyDiamond Bailey
Individual and Family Plan Correspondent at Blue Shield of CAIndividual and Family Plan Correspondent at Blue Shield of CA
Amanda EstradaAmanda Estrada
CORRESPONDENCE PHONE SUPPORT at Blue Shield of CACORRESPONDENCE PHONE SUPPORT at Blue Shield of CA
Kimberly TessierKimberly Tessier
Medical Biller at CAL-MED CENTRAL BILLINGMedical Biller at CAL-MED CENTRAL BILLING