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Click here or scroll down to respond to this candidateCandidate's Name
Bonaire, Ga Street Address United StatesMobile: PHONE NUMBER AVAILABLEEmail: EMAIL AVAILABLEObjectiveResults-oriented professional with over 20 years operational, customer service, and sales experience. I have demonstrated success in leading and developing productive and highly motivated teams in rapidly changing and diverse environments. At this point I would like to get an opportunity to utilize my skills and business studies background and contribute to an organizations growth. My demonstrated success in leading and developing productive and highly motivated teams in rapidly changing and diverse environments have been positive thus far, and I will continue.Professional Experience:Appeals Analysis Lead (Equivalent to GS-12) November 2019 - Present Employer: Anthem Inc.Mason, Ohio40 hours/week, 8hr day, 5 days a weekDuties, Accomplishments and Related Skills: Prepare and brief the Directors on critical and non-critical issues, progress of projects and other important items. Compile data for reports. Advise Medicare/Medicaid customers of coverage options. Explain Medicare Advantage plans include coverage for dental, vision, and hearing to customers. Assisted with developing center guidelines, policies, and procedures. Assists customers with Medigap coverage and deductibles. Conducts and documents thorough investigations of all complaint and grievance case types, communicating resolution to members in accordance with Center for Medicare and Medicaid. Delegate work, oversee progress towards goals, and coach team members as needed. Provide guidance and instruction to a working group about a project or portfolio of projects. Manage daily activities of the team. Analyze and evaluate data deficiencies and techniques and recommend process improvement methods. Gather and organize information on problems or procedures. Create meeting slides utilizing PowerPoint. Confer with personnel concerned to ensure successful functioning of newly implemented systems or procedures. Utilizes guidelines and review tools to conduct extensive research and analyze the grievance and appeal issues and pertinent claims and medical records to either approve or summarize and route to nursing and/or medical staff for review. Analyzes and renders determinations on assigned non-complex grievance and appeal issues and completion of the respective written communication documents to convey the determination.Accomplishments: Exceeded target goals for financial and payment accuracy. Awarded employee of the year for the center in 2019. Awarded employee of the quarter for the center 2020. Claims Adjudicator III November 2018 - November 2019 Employer: Anthem Inc.Mason, Ohio40 hours/week, 8hr day, 5 days a week Reviewed, analyzed, and processed claims in accordance with accreditation and regulatory requirements, with broad understanding of contracts, coordination of benefits, and healthcare terminology. Reviewed medical claims for accuracy and completeness, analyzing complex edits, making determinations on claims based on established guidelines and laws. Account and inventory management with a focus on timeliness. Prepared insurance claim forms or related documents and review them for completeness. Accomplished success in a production environment. Calculated amount of claim. Transmitted claims for payment or further investigation. Compiled, coded, categorized, calculated, tabulated, audited, or verified information or data. Appropriately generated, maintains, and corrects data from forms and computer reports. Appeals Analyst January 2016 - November 2018Employer: Express ScriptsMason, Ohio40 hours/week, 8hr day, 5 days a week Read incoming appeals letters and approve or deny based on plans criteria Assist clients with approval regulations Assist patients, doctors, and plans with benefit information Explain benefits for DOD, Medicare, Medicaid, and Anthem Participate in process improvement meetings and/or discussions, recommending process efficiencies and/or strategies for improvement. Serve as liaison between grievances and appeals and /or medical management, legal, and/or service operations and other internal departments. Check data for recording errors. Document findings of study and prepare recommendations for implementation of new systems, procedures, or organizational changes. Teaches and trains others regularly. Compile data or documentation. Plan study of work problems and procedures, such as organizational change, communications, information flow, and integrated production methods. Contact insured or other involved persons to obtain missing information. Provides support to clinical appeals, facilitating member verbal and written notification and correct authorization of services. Handling denials/appeals received from third party payers, managed care companies and/or government entities/auditors. Compose and complete oral and written responses to all parties. Prior Authorization Lead November 2012 - January 2016 Employer: Express ScriptsMason, Ohio40 hours/week, 8hr day, 5 days a week Assist clients, physicians, pharmacists, and patients in obtaining medically necessary medications as defined by their criteria. Process reviews in a timely fashion both over the phone and through written correspondence (faxes). Provide excellent customer service, by being knowledgeable, patient, and courteous. Research problem issues to provide the best outcome possible for our patients. Handle inbound telephone and written inquiries from pharmacists and doctors regarding prior authorization by screening and reviewing requests based on benefit plan design, client specifics and clinical criteria. Provide information to clients, participants, pharmacists and doctors regarding participants pharmacy benefit, drug coverage and provide accurate procedures for medication exceptions. Facilitate resolution of drug coverage issues and pro-actively address, research and resolve issues while maintaining accurate and complete documentation of all inquiries for continuous improvement. Work collaboratively with other associates and supervisor to ensure that best practices are shared.Sales Team Lead November 2009 - January 2016Employer: Gap, Inc.Cincinnati, Ohio30-40 hours/week, 5-8hr day, 5-6 days a week Provided training for new and existing employees Responsible for new market displays, and promotional offers Greet customers and ascertain what each customer wants or needs. Computed sales prices, total purchases, and receive and process cash or credit payment. Prepared merchandise for purchase. Establish professional relationships with customers that creates customer loyalty Consistently meet and exceeds corporate and regional goal/targets. Resolved customer complaints regarding sales and service. Investigated known or suspected internal theft, external theft. Answered questions regarding the store and its merchandise. Greet customers and ascertain what each customer wants or needs. Open and close cash registers, performing tasks such as counting money, separating charge slips, coupons, and vouchers, balancing cash drawers, and making deposits. Provide staff with assistance in performing difficult or complicated duties. Examine merchandise to ensure correct pricing and display, and that it functions as advertised. Directed and supervised employees engaged in sales, inventory-taking, reconciling cash receipts, or performing specific services Created and distributed staff schedules and monitor schedule compliance. Assisted with hiring and interviewing as well as resource planning. Invested in associate engagement. Drove improvements in employee satisfaction and diversity awareness. Realtor April 2006 - January 2009Employer: Comey & Shepherd RealtorsCincinnati, Ohio30-40 hours/week, 5-8hr day, 5-6 days a week Provided guidance and expertise in buying or selling of real-estate Offering financial tools. Establish business contacts and maintain customer retention. Acted as an intermediary in negotiations between buyers and sellers, generally representing one or the other. Prepare documents such as representation contracts, purchase agreements, closing statements, deeds, and leases. Assisted clients determine the value of property they want to sell. Presented purchase offers to sellers for consideration. Generated lists of properties that are compatible with buyers' needs and financial resources. Prepared market analysis statistics. Provided tips to help sellers stage property so that it will appeal to buyers. Advertised listed property to other Realtors and potential buyers. Hosted "caravans" during which other real estate agents tour the property. Hosted open house events. Negotiated contracts with buyers and/or agents acting on their behalf. Educated sellers about disclosure requirements. Facilitated the closing process on behalf of clients. Conferred with escrow companies, lenders, home inspectors, and pest control operators to ensure that terms and conditions of purchase agreements are met before closing dates. Software skills: Regularly utilize Microsoft Outlook to check emails. Regularly utilize Microsoft Word. Regularly utilize Microsoft Excel to create spreadsheet data. Regularly utilize Microsoft PowerPoint to create charts and flyers. Regularly utilize Microsoft Teams for meetings and messaging. Regularly utilize Microsoft SharePoint Regularly utilize Adobe Acrobat to create documents and instructions. Education:Fort Valley State University, Fort Valley, GA Graduated Bachelor of Arts in Language ArtsREFERENCESAvailable on request |
