CHERYL THOMAS
1110 Grove Park Drive S Orange Park,FL
Summary
Qualified Customer Service Advocate with 35 years in fast-paced customer service and call center environments. Personable and professional under pressure. Superior computer skills and telephone etiquette. Excellent reputation for resolving problems and improving customer satisfaction. Current in business systems and new technologies by continuously upgrading skills in the work setting.
Overview
36
36
years of professional experience
Work History
Service Advocate IV/Clinical Review
Florida Blue
Remote/Jacksonville, FL
01.2017 - 10.2020
- Focused on servicing current or potential customers, providers, agents, brokers, benefit administrators and consultants. Major accountability of this role was creating inpatient and outpatient authorizations, assisting Registered Nurses with getting authorizations ready for review. Managed over 40 customer calls per day. Responsible for creating authorizations for benefit administrators to ensure consultant satisfaction
- Provided customer service to plan members and/or providers by answering benefit questions, researching and resolving issues and inquiries and ensuring members and providers understand Company's products and services.
- Acted as liaison between hospitals, physicians, health plans, vendors, patients or referral sources.
- Initiated and managed clinical referrals for members and providers.
- Verified Insurance coverage and obtained authorizations when needed.
- Entered referral and documented communications, actions and other data in departmental systems.
- Determined contract and benefit eligibility; provided authorizations for inpatient, outpatient admissions nationwide providing certification and/or prior authorization requests. Referred cases requiring clinical review to Registered Nurses or Medical Director.
Remote/Customer Service Advocate III-State Plan
Florida Blue
Jacksonville, FL
11.1999 - 12.2016
- Investigated and resolved customer inquiries and complaints, timely with empathetic manner.
- Ensured superior customer experience by addressing customer concerns, demonstrating empathy and resolving problems.
- Learned, referenced and applied product knowledge information.
- Answered 35-40 calls per day by addressing customer inquiries, solving problems and providing new product information.
- Chosen to participate in Company Video of "Customer Experience."
- Responsible for dedicated account answering telephone and written inquiries, reopens, and or adjustments adhering to State Guidelines.
- Educated and encouraged customers to promote self-sufficiency with online and mobile access tools.
- Supported call center associates by taking on escalated calls, handling complex concerns and achieving customer satisfaction targets.
- Conferred with customers about concerns with products or services to resolve problems for members and providers by educating them with their benefits information as well as claims research, reprocess for State Group Members
- Educated members and providers on benefits information regarding State Employees' Group Health Plan.
- Evaluated trends and recommended enhancements to customer service policies, boosting team performance and customer satisfaction scores.
Subject Matter Expert; Appeals Coordinator
BCBSMA - Federal Employee Program
Rockland, MA
10.1993 - 10.1999
- Directed calls to appropriate individuals within correct departments.
- Managed wide variety of customer service and administrative tasks to resolve customer issues quickly and efficiently.
- Managed and responded to incoming written Appeal's for all Members that had Federal Employee Program nation wide. Responded to all written Appeal's within 30 day deadline, as per both, Office Of Personal Management, Federal Employee Program.
- Achieved performance requirements by responding to Subscriber Reconsideration's within thirty day deadline as per Federal Guidelines.
- Monitored and maintained all individual and team inventory.
- Trained new hire's in training room in preparation for Open Enrollment
- Attended Health Benefits Seminars and answered questions for potential subscriber's for both Preferred Provider Organization as well as Point of Service Plan during Open Enrollment
- Politely assisted Federal Employees via incoming calls, answered questions pertaining to Appeal, gave status, Appeal process
- Provided Ideas/Suggestions for continuous Improvement programs that complemented job responsibilities. Lead analysis of key production metrics in Durable Medical Equipment to develop summaries and suggest procedural modifications to optimize productivity
- Demonstrated self-reliance by meeting and exceeding workflow needs
Durable Medical Equipment Appeals Advocate
Blue Cross and Blue Shield of MA
Weymouth, MA
10.1991 - 10.1993
- Responsible for responding to Provider and Beneficiaries Appeals or requests for review of either denied claims or low allowances per HCFA Guidelines.
- Undertook extensive research with results in timely manner.
- Politely assisted customers via telephone.
- Verified Medical Coverage Guidelines to ensure provider was in compliance with Durable Medical Equipment Appeal
- Production basis, had to complete seven appeals via batches within one hour
Medicare Part "B" - Claims Processor
Blue Cross and Blue Shield of MA
Weymouth, MA
10.1989 - 10.1991
- Keyed all HCFA and UB04's by batch into computer system In order to maximize performance levels, processed all suspense investigates in accurate and timely manner via production.
- Identified and investigated system discrepancies and followed through with proposed resolution.
- Exhibited and promoted spirit of teamwork and contributed ideas for division and company success.
Customer Service Representative II
General Electric Dedicated, Blue Cross and Blue Shield of MA
Quincy, MA
10.1985 - 10.1989
- Reprocessed, adjudicated, and adjusted claims per GE Contract Guidelines.
- Administered General Electric Contract to GE members via General Electric Employees, Investigated, resolved customer inquiries (written and telephone).
- Scored in top 10% of employees in successful resolution of issues Managed wide variety of customer service and administrative tasks to resolve customer issues quickly and efficiently.
- Recipient of multiple positive reviews, member accolades acknowledging dedication to excellent customer service.
- Directed calls to appropriate individuals and departments.
- Assisted approximately 45 customers each day with benefit questions
- Asked probing questions to determine service needs and accurately input information into electronic systems
- Evaluated customer account information to assess current issues and determine potential solutions
Claims Examiner
Medicare "A" Hospital, Blue Cross and Blue Shield of MA
Braintree, MA
02.1985 - 10.1985
- Responsible for heavy keying and entering inpatient hospital data by batch into computer system.
- Completed six batches consisting of 30 paper claims each to be inputted via system
- Energetic Work Attitude Sharp Problem Solver.
- Collaborated with claims department and industry anti-fraud organizations to resolve claims.
- Investigated and processed inpatient Medicare insurance claims for policyholders.
- Corrected CPT codes to properly classify Inpatient Medicare claims.
- Double-checked and reviewed documentation for denied and accepted insurance claims
- Reviewed claims to ensure accuracy, resulting in multiple claim reductions
Education
High School Diploma -
Hull High School
Hull, MASkills
- Strong Organizational Skills
- Complex problem-solving
- Strong knowledge of medical terminology
- Excellent written, verbal communication
- Medical Review Background
- Work Independently
- Problem Solver
- Superior Soft skills and Telephone Etiquette
- Typing 80 WPM
- MS Office, Word, some Excel, Outlook
Timeline
Service Advocate IV/Clinical Review
Florida Blue
01.2017 - 10.2020
Remote/Customer Service Advocate III-State Plan
Florida Blue
11.1999 - 12.2016
Subject Matter Expert; Appeals Coordinator
BCBSMA - Federal Employee Program
10.1993 - 10.1999
Durable Medical Equipment Appeals Advocate
Blue Cross and Blue Shield of MA
10.1991 - 10.1993
Medicare Part "B" - Claims Processor
Blue Cross and Blue Shield of MA
10.1989 - 10.1991
Customer Service Representative II
General Electric Dedicated, Blue Cross and Blue Shield of MA
10.1985 - 10.1989
Claims Examiner
Medicare "A" Hospital, Blue Cross and Blue Shield of MA
02.1985 - 10.1985
High School Diploma -
Hull High School
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