Brittney Kyles
Lauderhill,FL
Summary
Overview
9
9
years of professional experience
1
1
Certification
Work History
Quality Assurance Analyst
Enhance Health
10.2023 - 05.2024
- Performs phone quality reviews; monitors inbound and/or outbound calls to analyze and evaluate customer service skills against established phone quality metrics, including but not limited to, call process measurements, accuracy of information provided, tone of employee, effective call management, and demonstrated professionalism
- Documents quality issues and performance measures for management review; analyzes results, and recurring trends; provides feedback to management concerning these findings
- Responsible for providing reports for program assigned
- Demonstrates expert knowledge of all products and services and is accessible to resolve concerns or provide information as necessary
- Demonstrates, advocates, and reinforces a positive team environment, professionalism, and the need to present a positive image of the company when interacting with customers
- Together with Team Leader, provides feedback to customer service employees to offer positive reinforcement and drive continuous improvement.
Escalations/Grievance and Appeals Specialist
NationsBenefits
08.2021 - 05.2023
- Assist members with placing OTC orders
- Assist members with resolving issues with missing orders and items
- Educate members with their OTC and hearing benefits
- Assist members with finding providers and scheduling hearing test
- Handle escalations from the direct health plan/MEA
- Handle IT Tickets escalated from agents/supervisors
- Has access FIS( internal card system) as an additional resource to verify and render more information
- Handle outreaches to members to further probe to render a resolution
- Live chat support for agents, supervisors and team leads
- Keep track of member's issues via Excel sheets
- Work closely with BCBSRI and Alignment Health plans via Excel sheets
- Educate MEAs, Supervisors, and Floor support member/ plan issue resolutions
- Travel to different cities to attend meeting with Health plans to be educated on plan updates
- Create and follow up on IT Tickets
- Live email support for agents supervisors and team leads
- Access to Zoho ( IT ticket system)
- Identifies complaints (grievances), requests for coverage determinations or appeals, and possible fraud, waste or abuse to forward to the correct department for research and resolution
- Analyze and resolve verbal and written claims and authorization appeals from providers and pursue resolution of formal grievances from members
- Review each complaint and denial, contact customers to gather details of their case, document the process as it moves through the system, provide a report regarding case statistics, and prepare for appeal hearings.
- Process, review and submit claims
WFH Licensed Health Insurance Agent
Humana
06.2018 - 01.2021
- Receive incoming calls enrolling members and prospects in MAPD/PDP, Medicare supplement, Dental and Vision plans
- Make outbound calls following up with members on there current coverage and present the value of additional benefits that are being offered.
HumanaOne Licensed Agent
Convey Health Solutions
06.2015 - 01.2018
- Assist members with placing OTC orders
- Assist members with resolving issues with missing orders and items
- Educate members with their OTC and hearing benefits
- Assist members with finding providers and scheduling hearing test
- Handle escalations from the direct health plan/MEA
- Handle IT Tickets escalated from agents/supervisors
- Has access FIS( internal card system) as an additional resource to verify and render more information
- Handle outreaches to members to further probe to render a resolution
- Live chat support for agents, supervisors and team leads
- Keep track of member's issues via Excel sheets
- Work closely with BCBSRI and Alignment Health plans via Excel sheets
- Educate MEAs, Supervisors, and Floor support member/ plan issue resolutions
- Travel to different cities to attend meeting with Health plans to be educated on plan updates
- Create and follow up on IT Tickets
- Live email support for agents supervisors and team leads
- Access to Zoho ( IT ticket system)
- Identifies complaints (grievances), requests for coverage determinations or appeals, and possible fraud, waste or abuse to forward to the correct department for research and resolution
- Analyze and resolve verbal and written claims and authorization appeals from providers and pursue resolution of formal grievances from members
- Review each complaint and denial, contact customers to gather details of their case, document the process as it moves through the system, provide a report regarding case statistics, and prepare for appeal hearings.
- Process, review and submit claims
Education
Diploma - Medical Coding and Billing
Everest University
Pompano Beach, FL04.2011
Skills
- Data analysis skills
- HIPAA
- Customer service
- Research
- Statistics
- Communication skills
- Medicare
- Insurance verification
- Customer support
- Software troubleshooting
- Medical collection
- Professional billing
- Verification of benefits
- 5 years of work from home/ hybrid experience
- 3 years Claims processing experience
Certification
- Certified Professional Coder
- Certified Coding Specialist
Additional Information
Key Skills
CMS-1500 forms Microsoft Office Programs
ICD-9, CPT, HCPCS HIPAA&OSHA Compliance
Patient Scheduling Medical Terminology
Medicare and Medicaid Explanation of benefits
Insurance verification Modifiers
AD BANKER
July 2015
Licensed Health Agent
Workauthorization
Authorized to work in the US for any employer
Personal Information
- Willing To Relocate: Anywhere
- Title: Front Desk Agent
Timeline
Quality Assurance Analyst
Enhance Health
10.2023 - 05.2024
Escalations/Grievance and Appeals Specialist
NationsBenefits
08.2021 - 05.2023
WFH Licensed Health Insurance Agent
Humana
06.2018 - 01.2021
HumanaOne Licensed Agent
Convey Health Solutions
06.2015 - 01.2018
Diploma - Medical Coding and Billing
Everest University
- Certified Professional Coder
- Certified Coding Specialist
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