Jacqueline Scott has over 15 years of experience in the healthcare industry working in provider relations, contracts, claims processing, and appeals. Her experience includes working at Humana, Dell/Universal American Health Plan, BCBS Mercy Health, Wellcare Health Plan, and North Broward Hospital District in various roles managing provider networks, contracts, claims adjustment, and appeals according to Medicare and insurance guidelines. She has strong computer skills including Microsoft Office and claims processing systems.

1. JACQUELINE SCOTT
EXPERIENCE
October 2013 to Humana Inc
Present (Department is moving at
Of the month) Provider’s Contracts
 Complete contract forms, prepare change of address records,
and issue service discontinuance orders, using computers.
 Contact customers in order to respond to inquiries or to notify
them of claim investigation results and any planned
adjustments.
 Determine charges for services requested, collect deposits or
payments, and/or arrange for billing.
 Refer unresolved customer grievances to designated
departments for further investigation.
 Review claims adjustments, examining parts claimed to be
defective and approving or disapproving claims.
 Review insurance policy terms in order to determine whether a
particular loss is covered by insurance.
June 2012 to Dell (Universal American Health Plan)
August 2013 Grievance and Appeals Specialist
· Reviewed and processed Member's appeal, non-contracted
provider's appeal. Appeals are being processed based on
Medicare Guidelines.
 There are several level of appeals, claims are reviewed and
processed based on Medicare Managed Care Beneficiary
Grievance, Organization Determinations and Appeals
Applicable to Medicare Advantage Plans, Cost Plans and
Healthcare Prepayment Plans (HCPPs).
April 2011 to BCBS Mercy Health
February 2012 Provider Relation Coordinator and Network Specialist, Contract
Assignment
· Initiated outbound calls to qualify Providers as to their interest
level in contracting.
 Contracted with Providers and assist them in completing all
documents.
 Followed up on contract or credentialing information received
that is incomplete or missing.
 Properly document contacts made and schedule the follow up
call as appropriate.
 Educated Providers on all pertinent information relevant to a

2. participating provider, via the telephone and in person.
 Assisted with locating a dentist for Members when a contracted
one is not available.
 Maintained Provider Application files by tracking the file until
it is turned over to Credentialing.
 Called contracted Providers when contractual changes
influence the market.
 Followed Up on inquiries, term notices and other
communications received.
 Attended market meetings for assigned markets and provide
input as needed.
 Ability to travel and conduct individual in person meetings
with Providers.
 Understood the basic language within Provider Agreements.
 Understand the pertinent information within the Provider
Application.
 Conducted other miscellaneous calls as needed (1099s,
surveys, verifications).
 Facilitated resolution to Provider concerns.
 Obtained Provider testimonials.
October 2009 to Wellcare Health Plan
April 2011 Provider Relation Coordinator
 Responsible for Provider Credentialing, Provider Contracting,
reviewing and Assisting Provider Reps in educating providers
on plan benefits.
 Negotiation of Provider Agreement for FFS and Capitated
Service.
 Prepared letter of agreement, reviewing claims for incorrectly
denied due the provider contract.
December 2006 to North Broward Hospital District
January 2009 Outpatient Coordinator, Inpatient Hospital Billing, Member
Services and ER Unit Secretary
· Reviewed authorization request for outpatient service, coding
and reviewing patient’s medical history, medical records and
eligibility to determine if the procedure meets criteria.
 Scheduled with the appropriate facility throughout the District.
Procedures range from Physical Therapy, MRIs CT Scans,
behavior health, pain management, office visits, same day
surgeries, biopsies, mammograms etc.
 Medicare Part A Inpatient Billing, Inpatient Hospital Care in
Hospital like Critical Care, ICU, Imaging. Admissions
Encounters until Patient Discharge, Appeals, Claims
Reconsideration, ICD-9 CPT DRG and HCPC Coding, HIPPA

3. Compliance Guideline, Medicare and Medicaid Compliance,
Inpatient Counseling, Assisting with Skill Nursing Referrals as
well as Hospice.
 Inpatient billing from start to finish.
 Performed tasks required to ensure the timely and accurate
submission of insurance claims to all third party payers and
documents billing activity in the patient accounting system.
 Worked daily electronic billing file and submits insurance
claims to third party payers.
 Reviewed daily edit reports from the hospital billing system
and makes necessary corrections to allow electronic
submission.
 Assisted members of various Government funded programs
provided by the district. Coordinate benefits to provide need
care for the patient, to resolve any issues pertaining to district
doctors and member care.
 Admitted and discharged, maintained flow sheets to monitor
inpatient admits, verified insurance coverage and requested
authorization for admits within a 24 hour admit. Trauma unit to
order all tests requested by the ER physician on a STAT level.
Located and contacted the physician that service was needed.
December 1998 to Hip of NY/Vista Health Plan
June 2006 Adjustments, Grievances and Appeals Specialist
Provider Call Center Representative
Claim Adjuster and Claims Examiner
· Reviewed claims for payment, adjusted claims that were
processed and denied in error, reviewed authorizations for
inpatient and outpatient services, assisted providers in claim
disputes and assisted them with correctly billing claims
 Reviewed and entered all required claims data in the
processing system, applied providers specific contracts
information according to the negotiated financial arrangements
for each billed service, executed general claims procedures and
guidelines including authorization/referrals as required, applied
members benefits limitation and exclusions in relations to
billed services, and evaluated and identified systems error to
meet and exceed production goals
 Analyzed patient and medical information to identify and the
investigation of coordination of benefits such as subrogation,
workers compensation, also no-fault and processing claim
accordingly.
COMPUTER SKILLS Microsoft Office XP (Word, Excel, Access, Power Point),
Microsoft Project 2000, Microsoft Visio 2000, TOPS, NICE,

4. MHS, EPOCH, Emdeon, Facets, Macess, and Outlook