Amber Fuller

• Create and uphold comprehensive records of provider demographics and data that influence all claims payments, provider directories, and communications with providers.

• Guarantee that all requests for provider updates (including additions, modifications, and deletions) are thoroughly researched, analyzed, addressed, and executed with precision and promptness.

• Confirm the credentials of all medical providers in accordance with the standards set by Blue Cross Blue Shield.

• Manage provider information for case processing and directory purposes by applying business rules.

• Engaged with members to provide information and education regarding medical management programs.

• Conducted research, executed data entry, addressed member inquiries, and assisted clinicians in the Medical Management department with their interactions involving providers and members.

• Responded promptly and accurately to communications received via telephone, fax, or voicemail.

• Gathered non-clinical data and collected structured clinical data for preauthorization purposes.

• Verified the eligibility of healthcare service benefits, selecting benefit levels in accordance with contractual guidelines and ensuring HIPAA compliance.

• Formulated and revised policies and procedures to ensure adherence to statutory, regulatory, and local, state, and federal guidelines related to HIPAA, benefits administration, and general liability.

• Facilitated the Risk Assessment Program by efficiently managing and responding to telephone calls, faxes, or voice mail messages in a timely and precise manner.

• Oversaw and evaluated behavioral health services.

• Gathered non-clinical data and structured clinical data for preauthorization purposes.

• Verified eligibility for Health Care Services Benefits by selecting benefit levels in accordance with contract guidelines and conducting HIPAA verifications.

• Managed referral requests, predeterminations, and the benefits process, providing training to others as necessary.

• Identified suitable treatment resources and made recommendations for patients to access these services.

• Provided counseling and support to clients dealing with substance abuse issues related to drugs and alcohol.

• Coordinated referrals for addiction services tailored to the specific needs and preferences of individual clients.

• Facilitated the Risk Assessment Program by leading and executing assessment activities in accordance with HiTRUST standards.

• Evaluated existing operational procedures to identify security deficiencies in relation to established policies, standards, and best practices.

• Conducted data analysis to pinpoint discrepancies between security policies and practices, prepared comprehensive reports, and validated findings with stakeholders and the business entity seeking HiTRUST certification. Developed and maintained security assessment documentation.

• Updated the eGRC system with findings from assessments and corresponding action plans.

• Monitored the progress of assessment findings and action plans to ensure timely completion by relevant stakeholders.

• Anticipated client requirements throughout the assessment process and proactively devised solutions to facilitate compliance with the HiTRUST framework.

• Executed intricate conceptual analyses by aligning various assessment frameworks to guarantee thorough and consistent security compliance.

• Provided stakeholders and the business entity requesting HiTRUST certification with detailed explanations and information to foster a clear understanding of remediation efforts and ensure adherence to the HITRUST framework.

• Suggested modifications to the Information Security Office concerning enterprise security policies, control standards, and operational practices.