Angelia J. Smith
Pinson
Summary
Experienced with data analysis, process improvement, and workflow management. Utilizes analytical thinking to identify and address inefficiencies. Strong understanding of operational dynamics, ensuring smooth and effective process execution.
Overview
19
19
years of professional experience
Work History
Inquiry Processing Analyst
Blue Cross and Blue Shield of Alabama
09.2024 - Current
- Experience reviewing and processing incoming insurance claims, ensuring all necessary documentation is complete and accurate.
- Experience routing inquiries to correspondence for internal and external customers
- Apply insurance policies, procedures, and regulations to claims in determining the correct resolution of claims objectives and/or errors
- Communicating with claimants to gather more information and to explain decisions
- Conduct investigations when claims can appear fraudulent, includes legal issues, or has other complex circumstances
- Ensure that claims are managed in compliance with company policies and procedures
- Experience researching and interpreting ICD-10 Codes using multiple software and databases to complete necessary requirements to update and/or resolve claims
- Experience ensuring accurate and timely processing of workflow management to meet and exceed departmental goals
- Experience managing multiple projects with various priorities
- Experience generating reports for compiling and streamlining daily responsibilities
- Experience and proficient in multiple databases for timely and accurate job responsibilities such as Navigator, WDMS, RTM Chat, Beacon, QITS, Blue 2, BIR, Advanced Mechanics, Stop Tables etc.
- Providing internal and external customers, management, group executives etc., excellent communication, research, organizational and time management, manifesting elevated level of professionalism, performing job specific duties with special attention to accuracy, details and prioritizing multiple tasks
- Experience in Enrollments and Eligibility of Small Group, Merit and Individual enrollments, processing, researching, documenting, detailing, and providing claims inquiries for suspended benefits and services
- Experience providing technical support and solutions Internal and External customers
- Experience in a position with production, accuracy, and/or timeliness according to departmental guidelines and independent decision-making skills
- Experience Understanding multiple workflows and technologies
- Experience researching and providing detailed information regarding medical diagnostic codes to determine claims factors to pharmacy, physician, and member services
- Experience in compliance with daily, monthly goals to adhere to performance of departmental guidelines
- Experience in a position requiring production, accuracy, and timeliness
- Experience 10+ years mentoring new and existing employees with new and existing enrollment processes while adapting and adjusting to constant business changes as necessary
- Experience in a position interpreting and communicating information, orally and written
- Experience completing special projects and goals timely and with little or no supervision
- Experience supporting, district sales, marketing team performing extensive telephone work and complementing the sales process by handling follow-up concerns, reinforcing the plan decisions, and advising clients to return their paperwork
- Experience in providing detail benefits and general information via high volume call center
Certified Paraprofessional Instructional Assistant
Kelly Services Hoover & Jefferson County School District
09.2023 - 09.2024
- Assist in classroom activities, assignments, and/or materials under the direction of the classroom teacher for the purpose of supporting and reinforcing educational objectives
- Assist and reinforce instructions from specified lesson plans with individual and/or group of students with specified needs such as Autism, ADHD for clear understanding, expectations, and fulfillment of assignments
- Demonstrated experience in developing and building positive, nurturing, and respectful relationships with students, teachers, and staff
- Demonstrated experience communicating with teachers, principals, and other district personnel for the purpose of assisting in evaluating progress and/or implementing IEP objectives
- Implements under the supervision of assigned teachers, instructional programs, and lesson plans (e.g., reading, math, language comprehension, writing, computer, etc.) for the purpose of presenting and/or reinforcing learning concepts
- Observe and document behavioral patterns and learning challenges as characterized and implemented by special education guidelines
- Documenting details of daily events of academic and behavioral patterns and learning challenges
- Experience and knowledge in learning management technology systems and technologies related to enhancing learning abilities
- Assist in organizing the classroom and teaching materials, monitoring the classroom during lessons and testing, and minimizing distractions and disruptions
- Implements under the supervision of assigned teachers, behavioral plans designed by IEP team for students with behavior disorders or other special conditions for the purpose of presenting and/or reinforcing learning concepts
Small and Merit Group Enrollment Services/Customer Service
Blue Cross and Blue Shield of Alabama
08.2006 - 10.2022
- Experience and Knowledge in researching and resolving complex and escalated issues dealing with post-enrollment issues, and redirecting group clients to appropriate departments
- Experience performing peer QA reviews and documenting performance results
- Experience calculating, researching, collecting, and resolving group enrollment inquiries, billing discrepancies and adjusted balances through the use of electronic calculator and MRO billing system
- Experience in researching claims processes, interpreting diagnostic medical codes, claims inquiries and detailed sensitive information, and knowledgeable of medical and legal terminology
- Experience in high volume call center providing benefits, claims and general inquiries for District, Senior and Large Group Members
- Experience with billing procedures, 834 electronic files, and processing group contracts
- Experience and proficiency in Microsoft Office Suites that include PowerPoint, Word, Outlook and Excel
- Experience in system networks to adopt strategies for researching, monitoring, and improving key performance to achieve quality resolution, customer and service satisfaction and retention such as Membership Management System (MMS), Benefits Online (BOL), and Group Enrollment Maintenance (GEMS), which includes interpreting coverage tables and Frontline Education Systems (Payroll and Time Systems)
- Experience in several database query tools such as IC Business Manager, Interaction Desktop, Oracle, Rate Quote Tools, Rate Verification, Excel, Lotus, Total View, Electronic Payment, (Marketing Tools, Maintenance Repair Operating (MRO), Documentation Online Reference System (DORS), and Customer Information Systems (CIS), Customer Interaction Client (CIC), PEGA (Image System), PeopleSoft, and Oracle
Education
Master of Business Administration/Masters Healthcare Administration -
Ashford University Clinton, IA-University of Arizona
04.2012
Skills
- Customer service
- Problem-solving
- Time management
- Attention to detail
- Claims investigation
- Organizing and prioritizing work
- Critical thinking
- Organizational skills
- Adaptability and flexibility
- Verbal and written communication
- Decision-making
- Analytical thinking
Timeline
Inquiry Processing Analyst
Blue Cross and Blue Shield of Alabama
09.2024 - Current
Certified Paraprofessional Instructional Assistant
Kelly Services Hoover & Jefferson County School District
09.2023 - 09.2024
Small and Merit Group Enrollment Services/Customer Service
Blue Cross and Blue Shield of Alabama
08.2006 - 10.2022
Master of Business Administration/Masters Healthcare Administration -
Ashford University Clinton, IA-University of Arizona
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