Cierra Wilson
Farmington Hills
Summary
Results-driven Senior Claims Analyst at Blue Cross and Blue Shield of Michigan, skilled in advanced data analytics and regulatory compliance. Enhanced claims processing efficiency through strategic decision-making and critical thinking, leading to improved customer satisfaction and streamlined workflows. Recognized for fostering a culture of continuous improvement and delivering impactful training programs.
Overview
12
12
years of professional experience
Work History
Senior Claims Analyst
Blue Cross And Blue Shield Of Michigan
Detroit, MI
08.2022 - Current
- Analyzed complex claims data to identify trends and discrepancies, ensuring accurate assessments.
- Collaborated with cross-functional teams to streamline claims processing workflows and enhance efficiency.
- Conducted thorough investigations on high-value claims, applying industry regulations and best practices.
- Developed training materials for claims processing analysts, fostering a culture of continuous learning and improvement.
- Reviewed and interpreted policy documents to ensure compliance during claims evaluations and decisions.
- Developed and implemented training programs in advanced analytical techniques, encouraging skill enhancement and knowledge exchange among team members.
- Increased accuracy in claims assessment through thorough investigation and diligent documentation of claim details.
- Maintained up-to-date knowledge of industry trends and regulatory changes, applying insights to enhance claim processing effectiveness.
- Played a critical role in interdepartmental initiatives aimed at improving overall organizational performance within the context of claims operations.
- Served as a subject matter expert on complex claim cases and projects, offering consultation and guidance on impacts to Medicare Advantage claims processing.
- Optimized resource allocation by effectively managing caseloads and prioritizing high-impact assignments.
- Contributed to policy improvements by identifying areas of potential risk exposure based on historical claim data analysis.
- Improved customer satisfaction by consistently resolving complex claims in a timely and professional manner.
- Coordinated and monitored claim adjustments and recoveries in relation to provider audits performed by Vendor organizations.
- Supported Mappo group integration into NASCO by proactively identifying and addressing significant process-related challenges.
- Delivered comprehensive training and guidance on claims processing within NASCO system to enhance team efficiency.
- Developed comprehensive claims processing desk-level procedures for MA claims processing team.
Senior Data Analyst
Blue Cross and Blue Shield of Michigan
Detroit, MI
02.2020 - 08.2022
- Conducted comprehensive data analysis to uncover trends, patterns, and insights.
- Utilized Business Objects and advanced reporting tools to extract and analyze data from data solutions and warehouses.
- Conducted root-cause analysis on data-related system issues to implement corrective actions.
- Facilitated communication between MA servicing department and Medicare claims operations teams.
- Facilitated alignment of initiatives to fulfill business objectives and enhance customer satisfaction.
- Oversaw customer relations by establishing effective communication processes and refining existing workflows.
- Optimized interfaces between computer systems to enhance information sharing.
- Leveraged coding expertise in ICD-10, CPT, HCPCS, revenue cycle management, DRG, and other industry-standard coding systems.
- Leveraged advanced expertise in benefits administration and claims processing.
- Conducted thorough research and analysis of claims to ensure compliance with CMS guidance.
- Led project management efforts as subject matter expert for MA and BCNA, focusing on clinical editing and Cotiviti software updates.
- Collaborated with provider consultants to resolve escalated claim and payment issues efficiently.
- Managed multiple projects while executing daily tasks and prioritizing workload based on deadlines.
Data Analyst
Blue Cross And Blue Shield Of Michigan
03.2019 - 02.2020
- Analyzed and proposed process enhancements to reduce operational risk in customer service.
- Facilitated comprehensive reporting to enhance strategic decision-making processes.
- Oversaw daily reporting metrics for multiple Medicare Advantage clients.
- Executed validation of results and conducted quality assurance to ensure data accuracy.
- Facilitated collaboration with management to establish efficient processes.
- Enhanced team knowledge and productivity through comprehensive training, monitoring, and guidance on best practices and regulatory protocols.
- Advocated for departmental interests in work groups and special assignments.
- Managed customer service inquiries and escalations to ensure timely resolution.
Customer Service Representative
Blue Cross And Blue Shield Of Michigan
Detroit, MI
08.2014 - 03.2019
- Facilitated effective and efficient handling of Medicare Advantage customer inquiries to enhance service delivery in a challenging call center setting.
- Communicated essential information regarding premium billing eligibility and claims processing to enhance customer understanding.
- Utilized IKA Gateway and IKA Enterprise to enhance customer satisfaction by resolving inquiries and complaints promptly.
- Reviewed alerts and relevant documentation to ensure timely and effective inquiry resolution.
- Conducted thorough investigations of issues to establish appropriate coverage and liability for claims.
- Conducted thorough analysis of claims to pinpoint system issues, facilitating timely corrective actions.
- Delivered outstanding customer service, earning numerous positive reviews that reflect dedication to client satisfaction.
- Cultivated a strong reputation as a reliable service provider, ensuring high standards of accuracy.
- Collaborated with contracted providers as a consultant liaison to streamline claim resolution efforts across various projects.
- Managed responses to provider claims inquiries to ensure timely resolution.
Education
High School Diploma -
John Glenn High School
Westland, MISkills
- Claims processing efficiency
- Strong negotiation skills
- Critical thinking
- Professionalism and integrity
- Strategic Decision-making
- Continuous improvement mindset
- Regulatory compliance awareness
- Ethical conduct standards
- Fraud detection techniques
- Advanced data analytics
- Claims analysis expertise
- Claims analysis
- Document workflow
- Claims trend analysis
- Problem-solving
- Problem-solving abilities
- Multitasking
- Verbal and written communication
- Decision-making
- Workload prioritization
- Analytical thinking
- Conflict resolution
- MS office
- Payment processing
- Microsoft Office Suite
- NASCO system and claims processing knowledge
- Extensive knowledge of CMS policies, guidance, and products
Timeline
Senior Claims Analyst
Blue Cross And Blue Shield Of Michigan
08.2022 - Current
Senior Data Analyst
Blue Cross and Blue Shield of Michigan
02.2020 - 08.2022
Data Analyst
Blue Cross And Blue Shield Of Michigan
03.2019 - 02.2020
Customer Service Representative
Blue Cross And Blue Shield Of Michigan
08.2014 - 03.2019
High School Diploma -
John Glenn High School