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Click here or scroll down to respond to this candidateCandidate's Name
EMAIL AVAILABLEWALLINGFORD, UNITED STATESPHONE NUMBER AVAILABLEDETAILSWallingford, United StatesPHONE NUMBER AVAILABLEEMAIL AVAILABLESKILLSCritical thinking and problem solvingCustomer ServiceAbility to MultitaskDecision MakingAbility to Work in a TeamLeadershipAdaptabilityEffective Time ManagementTeamworkCommunication SkillsAbility to Work Under PressureAbility to Learn QuicklyPROFILEDynamic Insurance Employee with drive and experience providing a superior level of customer service to members and providers. Bringing forth the ability to properly investigate claims, benefits, and provider contracts to resolve complex issues quickly in accordance with company and regulatory guidelines. Demonstrating consistent execution of best claim practices and a commitment to industry and company ethics.EMPLOYMENT HISTORYMultiple Roles at Anthem Blue Cross and Blue Shield, North HavenRoles listed by most current.March 1997 April 2024Provider Relationship Account ConsultantProviders contacted Anthem directly for contractual, payment (under or over) and claim concerns. I personally supported five hospitals and hundreds of Skilled Nursing Facilities.Reviewed and analyzed provider requests to investigate the outcome of claim payment or denial.Determined the appropriate resolution using strict adherence to internal guidelines, policies, and procedures.Worked with various departments, when necessary, to determine root cause and appropriate resolution.Identified impacted claims, ran impact reports, and followed the outlined process flow until all claims are rectified.Responsible for managing reconsideration escalations and may serve as a liaison between grievances & appeals and /or medical management, legal, service operations and/or other internal departments as appropriate.Set up and mediated meetings with Hospital and professional providers on workflows and system issues that are causing delays or errors in processing, following up with core areas to correct the issues for a cohesive process.Worked with contracting and reimbursement on setting up correct contracted rates for providers that are having discrepancies on payable codes or incorrect rates.Attended meetings with the provider team on best practices and utilized the strengths of the team to build upon the extensive knowledge of each of the team members.Assisted co-workers when they were backlogged to create a team atmosphere where everyone succeeded as one.Attended yearly training on Ethic and Compliance as required.Claims Adjustor IIIAnalyzed complex claims to determine validity and appropriate payment amounts.Analyzed claims data to identify fraud and abuse.Assisted in the development of new claims processes and procedures.Exceeded productivity and met quality monthly.Received cases from Member Services to adjust to pay claims correctly to ensure member satisfaction in a timely fashion.Processed various claim types (professional, institutional, Medicare, Medicaid)Worked directly with provider area to have claims corrected when provider called in with claim concerns in a timely fashion.Analyzed claims data to identify patterns and trends.Worked escalations in 24 hours to ensure member and provider satisfaction.Mentored co-workers on new work and current claims when they needed assistance on new products or workflows.Attended training on new products and process flows when applicable in used this knowledge to increase production or accuracy in adjusting claims.Member Service RepresentativeAnswered member calls to discuss their benefits, claims concern, appeals, and updated member information accurately and efficiently. (70-80 calls per day on average)Created cases that were assigned to the peripheral area for adjustment and followed up to ensure timelines were met per company and member standards.Mentored new service representatives when completing training.Assisted service researcher when they were backlogged due to my extensive claims knowledge and benefit understanding.Proposed new ideas to management to facilitate more efficient improvement is the service and claims area.Acted as resource for the provider on plan policies and procedures and questions on member eligibility and claims.Properly handled all member and provider inquires including primary care provider changes, clarification of benefits and claims processing questions.Called providers on behalf of the members to eliminate roadblocks in getting claims paid or appointments for services when the member was unable to obtain on their own.*Prior to 1997 work history available upon requestEDUCATIONSouthern Vermont College: Bennington, VermontBachelor of Science-Business Management-1990REFERENCESLynn Wilson from Anthem Blue Cross Blue ShieldEMAIL AVAILABLE PHONE NUMBER AVAILABLEKim Izzo from Anthem Blue Cross Blue ShieldEMAIL AVAILABLE PHONE NUMBER AVAILABLE/pre> |
