Beverly Coleman
Chicago,IL
Summary
Self-motivated healthcare and Insurance Professional with extensive team and leadership experience. Self-starter, highly motivated, goal oriented, strategic and client savvy; an effective problem solver with the ability to view problems in a positive way and propose solutions to improve work strategies. Intuitive ability to handle multiple tasks simultaneously, meets deadlines, work well under pressure, and adapts to change well. Successfully led multiple implementation projects, ensuring seamless integration and client satisfaction. Demonstrated expertise in project management and client relationship-building. Great communication skills and proven aptitude for developing a positive rapport with all ages, backgrounds, and management levels. Market knowledgeable of Group, Retail, and Government lines of business; ICP, FHP, MMAI, ACA, HMO, PPO, MA, and Market Place.
Overview
20
20
years of professional experience
Work History
Product Implementation Consultant
Blue Cross Blue Shield of Illinois for IFM
04.2022 - Current
- Collaborated with internal departments to confirm timely and accurate delivery and implementation of Network Projects.
- Managed project risks effectively, establishing contingency plans and proactive issue resolution strategies to minimize disruptions during implementation.
- Participated in ongoing professional development opportunities to stay current with industry trends and best practices in implementation consulting.
- Developed strong relationships with clients, fostering trust and long-term partnerships through professionalism and expertise.
- Streamlined project processes for enhanced efficiency and timely completion of implementation projects.
- Collaborated with cross-functional teams to ensure seamless integration and adoption of provider systems for new and expanding projects.
- Adapted quickly to new technologies and tools, ensuring the ability to provide top-notch service regardless of the specific systems being implemented.
- Managed multiple implementation projects concurrently, maintaining strict deadlines without compromising quality or scope.
Provider Network Consultant for Professional Medical Groups
Blue Cross Blue Shield of IL for Commercial and Government Programs
12.2017 - 04.2022
- Provide oversight of provider delegation responsibilities which include educating providers on new processes and initiatives
- Conduct monthly face to face meetings with assigned provider accounts to discuss provider performance and expectations
- Responsible for discussing and addressing quality measures with providers to include STARS and HEDIS gaps in care
- Responsible for maintaining relationships with contracted stakeholders within the service area including Cook, and DuPage counties
- Accountable for educating PCP/Specialty providers on company policy, procedures, payment structures, updates from the HFS, etc
- Conduct site visits to service providers, resolve issues, collect credentialing information, and review HEDIS/STARS information
- Manage multiple Initiatives presented by Business Consultants based on targeted territories, and grants provided to the Medical Groups
- Responsible for 13 large professional Medicaid accounts, that include HMO, Commercial PPO, Medicaid (ACA/FHP), and MMAI contracted providers; most accounts are high level, complex accounts
- Explain Encounter Rates, HFS Fee Schedules, risk contracts, and provide reporting on provider and/or Service Fund performance
- Promote continuous provider education to contracted stakeholders, regarding Provider Portal to assist with claims, authorizations/referrals, member benefits, member eligibility, etc
- Partner with Network Development team to pinpoint network gaps and suggests potential providers for recruitment to ensure network adequacy
- Accountable for the project management of Internal workgroups with Quality, Pharmacy, Compliance, and Utilization Management teams
- Discuss financial reporting, per the provider contract, on a monthly and quarterly basis
- Educate Providers on contracted vendors relationships with DentaQuest, Davis Vision, MotivCare, and Prime Therapeutics for the member population
Retail and Group Appeals Health Care Coordinator
Blue Cross Blue Shield of IL, TX, NM, OK, MT
05.2016 - 12.2017
- Collaborated with Appropriate EMO Leads and/or MD IIs to confirm Temp physician support for Weekend Coverage
- Managed Appeals Inventory Tracker/Daily Receipts, Production Reports, and All Open Appeals Report
- Managed Weekend On-Call Schedule for MD’s and facilitated morning EMO Daily Lead calls with MD II’s
- Handled EAA Appeals Assignments for QRS & CQRS while being Back up for Appeals Specialist II
- Coordinated & planned EMO HC Team meetings while creating & updating HC Library on SharePoint
- Handled Appeals MD Metrics for MD Training while monitoring Aerial Retail Homepages
- Created & Manage Medical Policy Errors Tracker for MRU, Route claims for MD’s and Locate missing FNOTS
- Opened/Closed queues in Image as needed for MD while maintaining Daily Queue report
Network Auditor
Blue Cross Blue Shield of IL (Kelly Staffing Services)
10.2015 - 05.2016
- Maintained spreadsheets and databases; collected, prepared, and distributed statistical data for daily and ad hoc reports
- Interfaced with credentialing staff to ensure data and systems are in sync while identifying gaps and risk in contracting processes
- Coordinated with multiple departments to ensure contracting processed were completed timely, accurately, and within required established standards and guidelines
- Performed research through online resources by contacting in-network providers for accurate demographic information
- Maintained providers’ status (i.e
- Deceased, retired, sanctions, etc.) to assure accuracy and lessen discrepancies to data for auditing
- Assisted Project Managers in various assignments for the HCM Ops and Projects Department
- Identified errors in captured data to ensure a 98% -100% accuracy rate for performance enhancement
- Analyzed performance results to identify trends and guided training efforts
Benefit Advisor
Global Employment Solutions/GoHealth
08.2014 - 10.2015
- Administered provider orientations and ongoing provider education, including writing, and updating orientation materials
- Consulted individuals with health and dental insurance policies on behalf of Blue Cross Blue Shield, during open enrollment for their renewal and discontinued coverage
- Conducted monthly meetings with the provider account representatives for documenting discussions and issues
- Interviewed prospective clients, obtained data concerning their financial resources and needs
- Reviewed policy requirements for fulfillment or necessary medical disclosures and qualifying clients for appropriate tax credits
- Exceeded sales goal of 200 monthly accounts becoming one of the top 25 sales agents for HCSC campaign
Provider Service Representative
IlliniCare/Centene Corp (Alta Staffing)
03.2015 - 09.2015
- Received and effectively responded to external provider related issues
- Educated providers on policies/procedures related to referrals, claims submission, web site usage, EDI solicitation and related topics
- Provided support to contract negotiators to ensure successful completion of contracting process
- Researched, resolved, and communicated provider network issues and changes
- Informed providers on prior authorization requirements with CPT codes, how to access services and other routine, non-clinical issues
- Coordinated with the Contracting Team regarding provider contracting and/or credentialing status
- Supported Data Entry team for new member enrollment while assisting Illini Care and County Care members on MCO government procedures and requirements
Insurance Agent Manager
Acceptance Insurance Co.
03.2005 - 12.2013
- Sold personal insurance products to individuals on behalf of First Acceptance Insurance
- Managed agency’s daily operations including strategic planning, outside marketing, human resource modeling, leadership technique, production methods and sales training of Customer Service Rep positions
- Developed marketing strategies to compete with other insurance companies
- Retained over 400 monthly accounts, maintaining monthly sales of over $100,000 in monthly premiums
- Required to inspect property by examining general condition, construction, age, and other characteristics to determine insurability
- Determined whether insurance procedures and processes complied with laws, regulations, and standards
Education
Property and Casualty Insurance License -
12.2024
Life and Health Insurance License -
12.2024
B.A. - Merchandising Management
International Academy of Design and Technology
06.2000
Skills
- Implementation management
- Requirements gathering
- Training delivery
- Training procedure implementation
- Stakeholder management
- Business analysis
- Soft Project management skills
- Client training
- Issue resolution
Technicalexperience
- MS Office Suite/Outlook, Teams
- Aerial, BlueStar, ECM, MPUI, EAA
- Facets/Claims Tool, Cotiviti
- Salesforce, Claims GUI, C3, RTB
- CRM, IEX, Portico, Trucare
- Amysis and Medi IL. State system
- Appeal Process and IER Process
- Mocha AS/400 and Broker Office, Quotepro Insurance Systems
- Five9 Communications Software, FFM Inventory Reporter/Pass Tool
- Premier Provider (PPW) Blue Access Emulator, Vistar, Fin Scan, Ace Desktop, Automation Team App, MUPI, FSS, IL License Database
Timeline
Product Implementation Consultant
Blue Cross Blue Shield of Illinois for IFM
04.2022 - Current
Provider Network Consultant for Professional Medical Groups
Blue Cross Blue Shield of IL for Commercial and Government Programs
12.2017 - 04.2022
Retail and Group Appeals Health Care Coordinator
Blue Cross Blue Shield of IL, TX, NM, OK, MT
05.2016 - 12.2017
Network Auditor
Blue Cross Blue Shield of IL (Kelly Staffing Services)
10.2015 - 05.2016
Provider Service Representative
IlliniCare/Centene Corp (Alta Staffing)
03.2015 - 09.2015
Benefit Advisor
Global Employment Solutions/GoHealth
08.2014 - 10.2015
Insurance Agent Manager
Acceptance Insurance Co.
03.2005 - 12.2013
Life and Health Insurance License -
B.A. - Merchandising Management
International Academy of Design and Technology
Property and Casualty Insurance License -
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