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Click here or scroll down to respond to this candidateCandidate's Name
PHONE NUMBER AVAILABLEStreet Address Charleston CoveMarion, AR Street Address
EMAIL AVAILABLEObjectiveTo obtain a career to utilize and add to my professional skills. To also obtain a challenging position that will foster growth and provide an opportunity to positively contribute to society and continuously improve my expertise and level of professional skills.Professional Profile Strong customer service portfolio (18+ years) Extensive Case management and claims processing experience with an ability to manage multiple tasks while remaining organized, disciplined and proactive. Directs and coordinates comprehensive programs that promotes self- sufficiency and independence. Strength in analyzing, researching, organizing, and problem solving Specializes in handling customer complaints with immediate resolutions Highly organized with the ability to set commitments with internal/external customers Effective oral and written communication skills Maintains a professional manner in a structured environment EducationMajor: Business Administration 2007-2008 Pulaski Technical College Major: Business Administration 2003-2004 UALRMajor: Business Administration 2000-2002 Phillips Co. Community U of A ExperienceAR Municipal League November 2019 PresentProvider Relations Representative Under the direction of the Director, I assist with the development and maintenance of the provider network to ensure adequacy of the network by securing evidence, electronically recording the evidence required and when applicable, prepares and records special determination of facts. For example, while completing a network exception and ensuring the provider is Candidate's Name
paid properly, I gather evidence, collaborate with management personnel, and prepares determination on spreadsheet. I am responsible for developing and managing relationships with providers by performing outreach, monitoring and resolving operational and/or contractual problems. For example, I identify network gaps and perform recruitment to address adequacy needs in the Network by completing new provider orientation for all applicable product lines. Utilizing Microsoft MS Teams, Ive coordinated meetings with providers to ensure payment accuracy as well as educated providers on payment contracts. For example, during a recent meeting a provider wanted to discuss an overpayment. I was able to share policy and procedures directly with the provider using screen share via MS Teams. Participates in audits and readiness assessments to assess contract compliance. For example, I plan and facilitate meetings that allows me to gather the evidence to ensure compliance. Exhibits understanding and sets priorities to handle multiple tasks simultaneously, and designs work plans to track progress, resolve issues, and efficiently and effectively see tasks to completion. I complete this task by working with providers to adhere to contract and regulatory requirements. Develops, investigates, and resolve claim actions that may involve suspension, resumption, adjustment, or termination of payments to providers. For example when a provider is out of network, I perform outreach to offer participation within our network. If the provider decides to accept, I then send them rates based on their provider type. Protects the rights of individuals by assuring patients and their personal representatives understand the legal rights and obligations under the Act and its relationship to other social welfare and benefits programs. For example, I often respond to contacts from providers on the patients behalf and research inquiries to make changes to the claims record. Establishes and maintains relationships with assigned healthcare providers through telephone calls, prompt resolution of issues, and excellent customer service. On a day to day basis I make contact with providers either via phone or email to ensure accuracy of provider rosters.AR Foundation for Medical Coverage January 2019 October 2019 Arkansas Works Specialist Processed eligibility updates by interviewing claimants for compliance and assisted clients with reporting responsibilities. Whenever there were changes in the claimants status or contact information I mailed call in notices to the claimant, obtained updated information and electronically stored the update to the system. Updated lapse in coverage and approved Exemptions when the claimant submitted Good Cause exceptions. I was able to complete this task by researching timeframes and ensuring the claimant had a valid good cause for the exception. For example, I had to determine mail stamp dates and review reasons for delay in response.Candidate's Name
Researched various issues related to membership, claims, eligibility, and benefits and received correspondence. By doing so, I was able to locate providers and receive/assign Physicians (from members request). Reported coordination of benefits to the proper departments. Once notification of another insurance was involved, primacy had to be determined. After reviewing all documentation I was able to make the proper referrals if needed.AR BlueCross BlueShield October 2011 December 2018 Tyson Elite/Plan 2 Plan Advisor Participated in critical activities such as strategic planning, compliance, complex financial/qualitative analysis that allowed me to analyze and explain claims process and procedure. For example, when the patients did not understand billing, I explained the Explanation of Benefits. Served as a direct contact for policy holders, providers, and other vendors. I assisted the providers by securing evidence from patients; electronically recording the evidence required. Coordinated with various BCBS plans of other states regarding medical record requests and follow up. I routinely participated in meetings utilizing innovative thinking to resolve complex benefit and claims issues. Provided follow up responses regarding claims and eligibility overrides with outside vendors. For example when the patient missed eligibility payments causing lapse in coverage, an override had to be completed upon remittance of payment. I collaborated with the patient and employers to ensure payments were retrieved and then proceeded with claims process. Assisted with training new staff and maintained adherence, availability, and dependability. For example, I completed formal training and side by sides to ensure the new hires were abreast of policy and procedures. I composed training material for future use of the new hires. Assisted all Medicaid Agencies with claims and eligibility inquiries. I supported the development and maintenance of relationships with both internal and external partners. I was able to maintain these working relationships by initiating work focused on business strategies, opportunities, and cost-saving efforts. For example, I linked Medicare Advantage and Medi-Pak plans. Confirmed receipt of Tyson appeals and forwarded appeals to the appropriate department.Hewlett-Packard 20102011TCO Escalations/Case Manager Provided tier support for internal staff. For example, I determined replacement of hardware and/or software using a large variety of templates, policies, and procedures. Assisted in monthly conference calls regarding workload management. We routinely met to discuss new ideas for replacement and warranty options. I conducted virtual troubleshooting and analyzed network issues, hardware failure, software issues, and reported issues to technical support for further review.Candidate's Name
Controlled escalations regarding customer complaints and equipment replacement and determined reasons for lack of shipment arrivals. Configured network controller via remote access and coordinated device swap-out on desktops, laptops, and printers. Generated labels for shipping and Inspected returned equipment and reviewed equipment fraud and managed equipment upgrades. References Available Upon request |
