Billie Carroll
Rochester
Summary
Dynamic Claims Adjuster with a proven track record at Next Insurance, excelling in claims investigation and denials management. Adept at navigating provider portals and delivering exceptional customer service, I leverage strong problem-solving skills to achieve optimal outcomes. Committed to accuracy and efficiency, I thrive in fast-paced environments while ensuring compliance with insurance policies.
Overview
8
8
years of professional experience
1
1
Certification
Work History
Claims Adjuster
Next Insurance
04.2022 - 08.2022
- Worked in tandem with the Claims Leadership Team to develop and implement claim settlement strategies on a claim-by-claim basis
- Provided feedback to Claim Specialists on claim results and audit results
- Worked inter-departmentally to investigate insurance claims and make a final determination of claim's status (paid, denied or pending further information)
- Managed emails and urgent claim requests, in addition to incoming/outgoing phone calls
- Drafted estimates for commercial clients and homeowners
- Reason for leaving: Reduction in Forces (layoff) due to the company's financial performance
Appeals Analyst
Excellus Blue Cross Blue Shield
Rochester
04.2021 - 04.2022
- Responsible for working grievances, appeals, inquiries and intangibles for all lines of business regardless of timeframes
- Compiles and provides DOL Requests for Information (RFI) to members.
- Meticulously document cases in a timely and professional manner ensuring that cases are easily understood.
- Provides written and/or oral responses to all cases/inquiries in appropriate business formats ensuring that the decision is communicated clearly and at the appropriate reading level to the customer as these decisions are binding for the corporation.
University of Rochester Dedicated Rep
Excellus Blue Cross Blue Shield
Rochester
09.2020 - 04.2021
- Responsible for handling incoming phone calls and providing excellent customer service
- Responsible for triaging care for member to provider
- Scheduling appointments for patients
- Disputing and resolving member and provider claim issues
Customer Care Advocate
Excellus Blue Cross Blue Shield
Rochester
04.2019 - 09.2020
- Provided customer service and technical assistance to members, prospective customers and business partners
- Responsible for documenting, researching and resolving inquiries from internal and external stakeholders who seek to consume our products
- Educated members on our services and understanding healthcare policies and their implementation in accordance with MTM, NCQA, HIPAA, NYSDOH, CMS and other legislative mandates
- Actively involved in outreach to stakeholders seeking interpretation of decisions and determinations related to claims, onboarding, effectuation, retention, provider inquiries and other complex inquiries
Personal Secretary- Director, Employee and Health Records
University of Rochester
Rochester
08.2018 - 01.2019
- Maintained hospital records in accordance with the institution's HIPAA and disclosure policies
- Preserved employee files in strict confidence and implemented privacy safeguards
- Demonstrated proficiency in medical terminology and healthcare related references
- Responsible for scheduling appointments, insurance verification and related pre-visit activities
- Compiled and electronically uploaded medical charts, reports, and correspondence
- Assisted in developing and implementing departmental goals and objectives
- Worked with the director to coordinate and supervise daily operations
- Ensured compliance with organizational regulations and internal policies
Account Review Unit Administrator/Customer Service Rep III
Maximus Federal Reserve
Rochester
08.2017 - 07.2018
- Responsibilities included resolving denials by Managed Care Organizations in accordance with healthcare regulations
- Proficient in understanding and de-escalating complaints and appeals
- Responded to written and verbal requests or complaints from clients that pertained to the administration of Medicare Advantage plans
- Scheduled Appeal Hearings utilizing approved client schedules and mandated protocol
- Responsible for answering incoming calls from Marketplace consumers seeking information on Medicare managed care plans, including but not limited to benefits, exclusions and general information
- Assisted eligible individuals and families with applying for health care coverage through the New York State Marketplace Exchange, in addition to providing enrollment instructions and assistance with the online portal
- Maintained correspondence from the health plan and the provider, via email and or fax, in accordance with departmental policy
- Working with Navigators and Brokers to set up meetings, as well as COB for HARP members
College Help Desk Specialist/Technical Support
Ellucian
Rochester
06.2016 - 08.2016
- Enrolled and updated online accounts assigned to students enrolled in online courses
- Assisted Professors with the electronic Black Board and development of online curriculums
- Worked in technical support assisting students and college personnel encountering website problems
Billing Specialist and Customer Care Consultants
Sutherland Global Services
Rochester
07.2015 - 05.2016
- Responsible for enrolling customers into multiple database systems and computer programs
- Provided exceptional customer service skills with efficient and positive results
- Corrected billing errors and supported the sale of consumer products
Intake Coordinator
eCardio Diagnostic (Independent Diagnostic Testing Facility)
10.2014 - 04.2015
- Responsible for enrolling cardiology patients and coordinating cardiac event monitoring services
- Contacted physician offices to confirm cardiac device orders and assigned devices for shipping
- Verified patient insurance and patient demographics
- Assisted with setting-up payment plans and other financial assistance options for patients in need
Education
Cosmetology
Empire Beauty School
Rochester, New York05.2023
Human Resources
Alfred State College
Alfred, New York01.2014
High School -
Edison Career and Technology High School
Rochester, New York01.2012
Skills
- Customer service and support
- Insurance verification and appeals
- Claims denials management
- Microsoft Office Suite proficiency
- Centricity and EPIC expertise
- Availity and provider portals navigation
- Membership and enrollment processes
- Emendy and eClinical knowledge
- Problem solving and critical thinking
- Attention to detail and accuracy
- Time management strategies
- Claims investigation techniques
- Workflow management skills
- Record preparation efficiency
- Advanced computer skills
- Insurance policy coverage expertise
References
Available upon request
Certification
CPR / AED Certificate
Timeline
Claims Adjuster
Next Insurance
04.2022 - 08.2022
Appeals Analyst
Excellus Blue Cross Blue Shield
04.2021 - 04.2022
University of Rochester Dedicated Rep
Excellus Blue Cross Blue Shield
09.2020 - 04.2021
Customer Care Advocate
Excellus Blue Cross Blue Shield
04.2019 - 09.2020
Personal Secretary- Director, Employee and Health Records
University of Rochester
08.2018 - 01.2019
Account Review Unit Administrator/Customer Service Rep III
Maximus Federal Reserve
08.2017 - 07.2018
College Help Desk Specialist/Technical Support
Ellucian
06.2016 - 08.2016
Billing Specialist and Customer Care Consultants
Sutherland Global Services
07.2015 - 05.2016
Intake Coordinator
eCardio Diagnostic (Independent Diagnostic Testing Facility)
10.2014 - 04.2015
Cosmetology
Empire Beauty School
Human Resources
Alfred State College
High School -
Edison Career and Technology High School