Category: ADVOCATE

         SERVICE ADVOCATE IV- CLINICAL SUPPORT         Summary     Over 10 years of the insurance industry experience. Strong analytical, documentation and research skills.       Highlights          Extensive insurance industry and regulatory compliance knowledge.  Quality assurance by conducting audits experience.  Analyze issues, tack trending and implement process improvement ideas.  Research, develop, editing and publish procedures for the department.  Strong interpersonal and communication skills  Report writing       Experience managing complex and time sensitive projects.  Provide important communications regard updates to procedures.  Claims file management processes  Medical terminology specialist  Database management  All Lines Claims Adjuster Licensed 6-20 State of Florida            Experience      Company Name    City  ,   State    Service Advocate IV- Clinical Support   01/2015   to   Current      • Assist providers with the entry and update of requests for medical clearances   • Research, coordinate and resolve inquiries and claims exceptions   • Coordinate with other Provider Service areas to identify formal education opportunities   • Identify, document and monitor process improvements   •Maintain records, reports, or files  • Moderate to heavy keying required.  • 9+ years' experience in health insurance, provider's office (handling medical coding, filing insurance claims or referrals) or a managed healthcare telephone service center   • Experience working with healthcare products including researching and resolving provider inquiries and working with provider contracts and networks   • Experience working with medical terminology, CPT-4 coding, ICD-9 coding and claims adjudication inquiry resolution processes and procedures   • Experience working with BCBSF healthcare products  *Review contract benefits and approve services for claims payment.  *Examine claim forms and other records to determine insurance coverage  *Verify investigative information   *Maintain insurance records               Company Name    City  ,   State    Service Advocate V- Sales Support Agent Service   08/2013   to   01/2015       Knowledge of all lines of business to include Over 65, MIPPA, Medicare Advantage, Under 65 Health Care Reform plans, BlueCare HMO, Blue Options PPO, Blue Select PPO, Underwritten plans, Ancillary products such as Dental and Life, Small and Large Group, and Claims.  Processing systems experience   Detailed knowledge of the enrollment processes and work flow   Assist agents with day to day inquiries  Train and educate agents on products, procedures and applicable rules and regulations.  Research and resolve system issues an agent may have.  Research and resolve all inquiries both sales-related and service -related for all lines of business and all health and ancillary products.  Research information and implement solutions for sales partners whose needs demand agility and persistence.  Collaboration relationship building with external partners, such as sales agents, brokers, consultants, key accounts, providers or vendors.  Experience working with Sales or Sales Operational areas Demonstrated experience managing multiple priorities and demands.          Company Name    City  ,   State    Service Advocate IV- Enrollment Maintenance and Billing   03/2007   to   08/2013       Knowledge of all lines of Over 65, MIPPA, MedAdvantage, Under 65 Healthcare Reform plans to include BlueCare HMO, Blue Options PPO, Blue Select PPO, Underwritten plans, Ancillary products such as Dental and Life.  Document, monitor and track call performance for compliance  Create, track and implement any identified process improvement items.  Create reports to upper management to identify any delays or estimated completion dates or actual implementations.  Monitor Inventory for timeliness, research any outliers.  Prepare SQM research, collecting and summarizing data, identifying trends and root cause analysis.  Serve as a SME for internal and external customers to resolve consumer market enrollment, maintenance, membership and billing issues.  Leader of the Senior Market Continuous Improvement Team: Supports continuous improvement efforts through the early identification, investigation and resolution of problems by communicating and coordinating with the appropriate contacts for completion.  Serving on a Process improvement work group   Project management and implementation process improvement items.  Monitor Supervisor callbacks and multiple locations for timeliness and completion within metrics and handle escalated issues, etc.  Invoices and reconciles premium income.  Maintain knowledge for government and regulatory laws and changes.          Education        All Lines Claims Adjuster   2014     Florida State College at Jacksonville  ,   City  ,   State       6-20 All Lines Claims Adjuster         Bachelor of Arts  :  Psychology   2004     University of North Florida  ,   City  ,   State        Psychology with Social Welfare Minor  Strong analytical, organization, research, communication and documentation skills.         Bachelor of Science  :  Nursing   2001     Jacksonville University  ,   City  ,   State  ,   USA     Nursing  Submit claims items, document progress of patient throughout care. Create plan of care and document progress until discharge.         Associate of Arts  :  Psychology   2000     St Johns River Community College  ,   City  ,   State       Strong writing skills and actively wrote for the college newspaper.         Skills     Healthcare: claims authorization, computerized and paper claims submission People skills: advanced problem-solving, great organizational skills