Category: ADVOCATE

         ASSOCIATE CLAIM PROCESSOR/MEMBER SERVICE ADVOCATE       Summary     After 29 years' of working in an industry that puts people at the forefront of their business, I have a proven track record of    
       building and maintaining relationships and an impeccable customer service background. My objective is to continue to put people first, build strong and long last relationships and to use my expertise in the customer service field, to give the customer an exceptional experience.         Skills          Customer service  Verbal and written communication  Team collaboration   Problem solving and decision making    Strong Analytics       Strong work ethic  Working independently and in a team environment   Strong leadership  Interpersonal skills             Experience     05/2013   to   Current     Associate Claim Processor/Member Service Advocate    Company Name   －   City  ,   State      Receive calls from customers regarding coordination of benefits  Respond accurately and promptly to customer concerns   Update system with additional insurance information   Initiate calls to providers to verify or request additional information required for accurate processing  Keep records of customer transactions and detail comments of inquiries  Organize customer inquiries to meet specific time frames   Examine new claims for pertinent information required for initial claim entry.  Evaluate and apply policies and procedures implemented for the processing of claims.  Review and execute request from internal departments,  providing feedback on findings  Research and execute adjustments on claims processed incorrectly   Resolve claim suspends by using the proper reference guides and systems for resolution.  Accountable for researching history records when determining claim processing issues and providing claim status to the lead processor and supervisor  Review claims for Coordination of Benefits with Medicare, Medicaid, and other insurance carriers  Collaborate daily with supervisor's, team leads and team members, to provide exemplary service to our customers         07/2011   to   05/2013     Claim Processor    Company Name   －   City  ,   State      Evaluated new provider and customer claims for information required for processing.  Identified claim discrepancies and determined appropriate resolution in processing.  Determined if claims should be returned, denied, or adjudicated based on policy and procedure manuals.  Trained temporary staff and new hire employees on claim processing, policies and procedures, and system applications.  Provided feedback to management regarding the progress of temporary staff and new hires and gave additional training and assistance where needed.  Reviewed and resolved claim inquiries regarding under/overpayments, benefits, pricing and rate issues.  Manually priced claims based on provider contract and required information.  Participated in and tested new systems during implementation and configuration of Highmark applications prior to turnkey.  Evaluated and tested new or managed care software programs and development
procedures used to verify that programs function according to user requirements.  Performed plan testing and produced status updates to management.  Systems used: TBS, BlueChip, IDM, ITS/Formats, BlueSquared, OCR.         07/2010   to   07/2011     Customer Service Representative    Company Name   －   City  ,   State      Managed customer and provider calls regarding benefits, eligibility and claims.  Reviewed benefits for understanding of applications and benefits.  Requested identification cards and Certificates of Credible Coverage.  Collaborated with providers in resolving claims issues in an effort to provide excellent service to our members.  Provided timely resolution and callback to provider's and customers regarding concerns.  Assisted members with online navigation of the BCBSDE website and assisted providers with NaviNet.  Systems used: TBS, BlueChip, IDM, ITS/Formats, Avaya Phone system.         01/2008   to   07/2009     Team Lead/BlueCard Host Adjustments    Company Name   －   City  ,   State      Provided subject matter direction to team members and assisted with complex claim issues.  Educated team on new claim processes, new and updated procedures, and system updates.  Performed audits on randomly selected letters sent to provider's.  Provided assistance to the supervisor by managing workflow and delegating work based on expertise.  Reported systems issues and benefit discrepancies to IT and configurations analyst.  Developed and modified letters to providers and contacted Home plans regarding claim issues.  Participated in compiling production reports and timesheets for management.  Reviewed and responded to inquiries from providers and BlueCard plans requesting adjustments to claims that were underpaid or overpaid.  Maintained production and quality standards.  Systems used: WGS, Inter-plan Messaging, Facets, ETM, Ultera, NetWorx, Citrix.         04/2007   to   01/2008     EDI Enrollment Specialist    Company Name   －   City  ,   State      Identified and resolved discrepancies on enrollment applications and group transmittals.  Processed request for additions, changes, reinstatements, and terminations.  Requested additional information as needed from marketing representatives, groups, and members.  Analyzed group enrollment forms for rate and tier changes, and updated MHS, Facets, MSIQ, and SLIQ.         12/2005   to   04/2007     Underwriting Assistant    Company Name   －   City  ,   State      Acted as a liaison to verify, research, track and monitor specific case issues.  Prepared information into MGU from specific, aggregate, benefits, and census reports.  Reviewed census, specific, and aggregate reports for correct calculations.  Followed up with client request and acted as a liaison for the customer and underwriter.  Provided support to underwriters in the quotation process for new business.  Gathered and input data into Sales and Underwriting systems to monitor and track quote activity.          Education and Training     Present       Behavioral Science    Wilmington University          Behavioral Science       1988       Accounting    Franklin Morris Business Academy          Accounting       1983     Diploma  :   General Studies    John W. Hallahan Catholic High School          General Studies        Skills    analyst, Avaya, Benefits, Citrix, client, direction, forms, IBM, insurance, letters, mainframe, managing, marketing, Messaging, SharePoint, navigation, OCR, Phone system, policies, pricing, processes, progress, quality, researching, research, Sales, supervisor, underwriter, Underwriting, website, workflow