Candice Nance
Jacksonville,FL
Summary
Enhanced expertise in insurance and claims operations, focusing on non-phone claims review and discrepancy resolution to ensure compliance and quality.
Overview
7
7
years of professional experience
Work History
Senior Claims Examiner
Aetna/CVS Health
01.2025 - Current
- Conducted Thorough Reviews Of Claims To Maintain Compliance With Established Policy Standards Within Plan Documents
- Engaged With Legal Teams To Address and Resolve Intricate Claim Disputes, Ensuring Compliance and Clarity.
- Facilitated Knowledge Transfer To Junior Examiners To Enhance Claims Processing and Assessment Efficiency.
- Refined Claims Review Workflows To Support Timely and Accurate Decision-Making.
- Implemented Strategies To Streamline Operations, Minimizing Processing Time and Improving Overall Efficiency.
- Oversaw The Implementation Of CPT, Benefit, and ICD-10 Coding Systems To Enhance Operational Efficiency. Coordinated Training Sessions For Staff On Coding Best Practices. Developed Strategies To Streamline Coding Processes and Improve Accuracy.
- Reviewed and Corrected Claims To Uphold Quality Standards and Maintain Compliance.
- Executed Daily Processing Of 120-150 Claims To Maintain Operational Efficiency.
Major Account Representative
BlueCross BlueShield of Tennessee
09.2024 - 02.2025
- Developed Comprehensive Knowledge Of Insurance Policies, Procedures, and Regulations To Insure Accurate and Timely Responses
- Successfully Verified Insurance Coverage For BCBST Members
- Resolved Complex Insurance Discrepancies In An Efficient Time Frame
- Established Positive Relationships With Providers, Patients, Other Insurance Providers, Etc. To Handle Information
- Communicated With Providers, Claim Specialists, As Well As Representatives In Regards To Patients and Their Policy To Ensure Benefits Were Applied Correctly To Deductibles, Copayments, and Coinsurance
- Utilizations Of Knowledge In Regards To CPT Codes To Verify That They Were Coded Correctly On Claims
Claims Adjuster
Blue Cross of Idaho-Boise, ID
10.2022 - 09.2024
- Independently Reviewed, Investigated, and Adjudicated Complex Medical Claims In A Non-phone, Production-Based Environment.
- Verified CPT, ICD-10, and HCPCS Codes To Ensure Proper Coding Practices and Benefits Application.
- Identified Policy Discrepancies, Eligibility Issues, and Network Limitations With Attention To Regulatory Compliance.
- Collaborated With Internal Teams and Systems To Support Audit Requests and Claims Adjustments.
- Delivered High-Quality Documentation With Attention To Detail In A Paperless, Remote Setting.
Patient Care Coordinator
Centene Corporation (Temp)
01.2022 - 10.2022
- Addressed patient needs and updated records, enhancing service quality and patient satisfaction.
- Educated patients on medical procedures, improving their understanding and product utilization.
- Maintained accurate patient data, ensuring seamless communication and service continuity.
- Communicated professionally, fostering better patient relationships and account comprehension.
Team Lead
LoanCare Service Link
01.2021 - 12.2021
- Led team in mortgage customer service, resolving complex issues efficiently.
- Guided agents in handling escalated mortgage queries, ensuring customer satisfaction.
- Managed call responses, achieving prompt resolution and follow-up.
- Facilitated agent training, enhancing problem-solving capabilities.
- Improved customer communication strategies, driving positive outcomes.
Customer Service Representative
Caritas (Temp)
07.2020 - 01.2021
- Efficiently answered calls within 5 seconds for Louisiana Medicaid members.
- Assisted members with medical, dental, and vision services inquiries.
- Managed provider calls regarding claim statuses with professionalism.
- Facilitated bilingual calls with interpreters, ensuring clear communication.
- Maintained high standards of service and professionalism throughout.
Loan Processor
Prudential (Temp)
01.2020 - 04.2020
- Developed document checklists for loan modifications, improving process efficiency.
- Addressed inquiries from internal teams and third parties, enhancing communication.
- Managed multiple tasks while ensuring confidentiality, demonstrating organizational skills.
- Organized customer files and maintained office systems, supporting workflow consistency.
Customer Service Representative
AmeriHealth Caritas (Temp)
07.2019 - 01.2020
- Answered calls swiftly, assisting Medicaid members with medical, dental, and vision inquiries.
- Managed provider calls regarding claim statuses, ensuring accurate and timely information.
- Conducted bilingual conference calls with interpreters, maintaining professionalism.
- Resolved member issues efficiently, contributing to improved service satisfaction.
- Demonstrated strong communication skills in a high-pressure, fast-paced environment.
Financial Analyst
Baptist Health (Temp)
01.2019 - 06.2019
- Handled patient calls, explained billing, insurance, and payment plans.
- Managed high call volume with professionalism.
- Ensured clear communication on financial matters.
- Facilitated payment plans for financial accessibility.
- Contributed to improved patient satisfaction.
Education
High School Diploma - undefined
William M. Raines High School
Jacksonville, FL12.2009
Skills
- Achieved improved client understanding of insurance policies and coverage options through effective guidance Enhanced claims processing efficiency by collaborating with team members Streamlined operational workflows by providing essential administrative support
- Produced impactful presentations that effectively conveyed key messages Guided team members in designing visual aids that improved meeting engagement Enhanced content organization, resulting in clearer communication outcomes
- Enhanced user experience with Microsoft Word by facilitating engagement Streamlined document formatting and editing processes to improve efficiency Fostered collaboration among teams on shared documents, resulting in improved productivity
- Enhanced data analysis and reporting by guiding teams in Excel utilization Created comprehensive spreadsheets with colleagues to track project milestones effectively Improved data retrieval efficiency by overseeing record organization
- Conducted detailed data entry tasks, ensuring streamlined operations and increased productivity
- Facilitated the management of claims processing workflows, enhancing both efficiency and accuracy in operations
- Demonstrated typing proficiency at 45 words per minute, ensuring effective communication and accurate record-keeping
Timeline
Senior Claims Examiner
Aetna/CVS Health
01.2025 - Current
Major Account Representative
BlueCross BlueShield of Tennessee
09.2024 - 02.2025
Claims Adjuster
Blue Cross of Idaho-Boise, ID
10.2022 - 09.2024
Patient Care Coordinator
Centene Corporation (Temp)
01.2022 - 10.2022
Team Lead
LoanCare Service Link
01.2021 - 12.2021
Customer Service Representative
Caritas (Temp)
07.2020 - 01.2021
Loan Processor
Prudential (Temp)
01.2020 - 04.2020
Customer Service Representative
AmeriHealth Caritas (Temp)
07.2019 - 01.2020
Financial Analyst
Baptist Health (Temp)
01.2019 - 06.2019
High School Diploma - undefined
William M. Raines High School