Alicia Thomas
Jacksonville,United States
Summary
Driven Analytical Professional With Strong Background in Providing Conflict Resolution. Resourceful in Gathering Relevant Information Regarding Disputes, Providing Appropriate Documentation and Guiding Both Individuals and Groups to Reach Satisfactory Agreements and Settle Complicated Issues. Devoted to Adhering to Ethical Guidelines and Laws Throughout All Casework.
Overview
1
1
Certification
28
28
years of professional experience
Work History
Medicaid Advanced Resolution Specialist
Humana
WAH, FL
01.2021 - Current
- Address customer needs, which may include complex benefit questions, resolving issues, and educating members.
- Submit expedited appeals
- Record details of inquiries, comments or complaints, transactions, or interactions and take action in accordance with it.
- Escalates unresolved and pending customer grievances.
- Regularly exercises discretion and judgement in prioritizing requests and interpreting and adapting procedures, processes and techniques.
- Work under limited guidance due to previous experience/breadth and depth of knowledge of administrative processes and organizational knowledge.
- Have full understanding of Medicaid processes.
- Strong attention to detail.
- Ability to manage multiple or competing priorities, including use of multiple computer applications simultaneously.
- Exhibit patience, kindness and understanding with the ability to handle escalated "Supervisory type" calls.
Inbound Contacts Representative
Humana
WAH, FL
01.2020 - 01.2021
- Take calls from customers, answer questions and address any concerns they might have.
- Provide excellent customer service to each customer.
- Create a task to follow-up if additional research is needed and make an outbound call to the customer with a resolution.
- The ability to listen to the customers need and/or issues and provide helpful solutions to their problems.
- De-escalate a problem to ensure that the proper result is obtained.
- Track customer interactions.
- Ensure that calls are fully authenticated.
- Obtain customer information over the phone, to explain processes and benefits.
- Follow Medicaid mentor documents in order to meet the processes and standards set forth by the organization.
Business Support Specialist
Florida Blue - Blue Cross Blue Shield Of Florida
Jacksonville, FL
01.2016 - 01.2020
- Create and manage reports for tracking and monitoring purposes.
- Research, analyze and review documented regulatory requirements.
- Identify gaps in process, recommend and implement process improvements.
- Develop and document Business Requirements for new and/or existing regulatory requirements for commercial and government products.
- Provide updates to compliance during our weekly meetings to discuss any changes to processes.
- Audit casework reports to identify process improvements, training issues, and/or system gaps.
- Effectively recommend, develop and coordinate timely communication to intern customers through relationship management, and enhancement of processes to ensure quality, compliance, minimal risk to the business and customer satisfaction.
- Act as a champion for change, provide guidance in a team and collaborative setting.
- Perform accurate and timely research, analysis and verification of information, data used to design, improve processes, workflow, products, and system efficiencies to ensure compliance is met or exceeded by completing V-Lookup.
- Support the complaint and efficient operation of processes and system performance through on-going monitoring/evaluation, develop specifications, output to ensure that superior customer service is being provided by the advocates.
- Efficient in working in a deadline driven environment.
- Lead and participate in staff meetings, employee meetings and team buildings.
- Strong communication skills are used primarily for verbal and written responses to CMS, Compliance, all levels of management, other internal business partners.
- Responsible for interviewing potential analyst, as needed.
- I was the direct point of contact for the new analyst.
- Provide day-to-day instruction and leadership to the new analyst.
- Submit time sheets for each analyst.
Quality Auditor
Florida Blue - Blue Cross Blue Shield Of Florida
Jacksonville, FL
01.2014 - 01.2016
- Audits Enrollment Membership and Billing for large and small Commercial accounts, and Under 65 Enrollment Membership and Billing teams to ensure that they are following procedures. In addition, I listen to their phone calls, and written inquiries.
- Document quality issues and performance measures for management review.
- Participates as a Subject Matter Experts in daily Quality Review Board to ensure all defects identified are in accordance to guidelines.
- Conducts detailed analysis to determine root causes of problems, identifies opportunities for improvement and submit process improvements.
- Provide coaching through side by sides and frontline two way communication meetings.
- Develop and/or revised all Standard Operating Procedures or Desktop Procedures for each line of business to ensure that the auditors were following the appropriate processes consecutively.
Service Advocate V/Team Lead
Florida Blue - Blue Cross Blue Shield Of Florida
Jacksonville, FL
01.1999 - 01.2014
- Responsible for the enrollment and billing for Group Enrollment (Corporate and Small Group Accounts). These accounts enroll for the following products: BlueChoice, BlueCare, BlueOptions, BlueMedicare, Comp D, Health Savings Account, Flexible Spending Accounts, to include ancillary products such as Life, Dental, and Vision.
- Ensure that all processes comply with the corporate business policies.
- Subject Matter Expert for Prime therapeutics to process any expedited enrollments for pharmacy.
- Subject Matter Expert for Availity, any team member would report if a member did not interface into all systems.
- Worked as a designated representative for Healthy Kids/Medicaid
- Worked as a designated representative for Florida Blues employees and retirees.
- Review group automated files via EVT and notify the appropriate internal/external customers to better utilize the interface process.
- Make changes to TSO for automated enrolled groups as well as transfer invoices into an Excel spreadsheet.
- Provide step-by-step methods for external customers to utilize the blues enroll system after a user id and password has been issued.
- Provide guidance to team members regarding processes and operational workflow issue resolution and decision making
- Trained all new hires.
- Provided day-to-day instructions on job duties.
- Viewed workforce management reports to discuss: Performance, call quality, call listening, to discuss areas of improvement, if applicable. Also, discussed average handle time.
Education
Associate of Science - Criminal Justice
Florida Metropolitan University
Jacksonville06.2003
Skills
- Issue Reporting
- Interviewing Abilities
- Critical Thinking
- Problem Resolution
- People Skills
- Relationship Building
- Reliable & Trustworthy
- Customer Service
- Team Building
- Computer Skills
- Friendly, Positive Attitude
- Basic Math
- Active Listening
- Conflict Resolution
- Flexible Schedule
- Microsoft Office
- Good Work Ethic
Certification
- Preparer Tax Identification Number
- Technology Fundamentals, Humana - 2022
Timeline
Medicaid Advanced Resolution Specialist
Humana
01.2021 - Current
Inbound Contacts Representative
Humana
01.2020 - 01.2021
Business Support Specialist
Florida Blue - Blue Cross Blue Shield Of Florida
01.2016 - 01.2020
Quality Auditor
Florida Blue - Blue Cross Blue Shield Of Florida
01.2014 - 01.2016
Service Advocate V/Team Lead
Florida Blue - Blue Cross Blue Shield Of Florida
01.1999 - 01.2014
Associate of Science - Criminal Justice
Florida Metropolitan University