Crystal Roy
Riverside,CA
Summary
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Experienced with analyzing and resolving appeals accurately and efficiently. Utilizes strong analytical skills to review cases and identify key issues. Track record of effective communication and collaboration, ensuring compliance and resolution.
Results-oriented professional in appeals analysis field. Proven ability to thoroughly review and resolve complex cases with high accuracy, ensuring compliance and customer satisfaction. Known for strong collaboration and adaptability, consistently meeting team goals and adapting to changing requirements. Key strengths include analytical problem-solving and effective communication.
Overview
19
19
years of professional experience
Work History
Grievances & Appeals Analyst
Anthem Blue Cross
01.2022 - Current
- Requesting medical records and updating coordination of benefits to verify if medicare is primary or secondary
- Problem solving and troubleshooting member's claims issues
- Cross trained 6 new employees on PPO, HMO, CDHP products
- Keyed member and professional claims
- Filing grievance and appeals
- Taking 80-90 incoming calls per day regarding billing issues, claim status, eligibility, insurance benefits and provider contracts
- Responded to customer questions via fax, telephone and written correspondence regarding their PPO, HMO and HRA plans
- Also made outbound calls to resolve issues
- Leveraged data analysis tools to track performance metrics, identifying trends in case outcomes that informed strategic decision-making efforts.
- Mentored new team members on departmental protocols and best practices, fostering a positive learning environment within the team.
- Reviewed, analyzed and processed non-complex grievances and appeals.
Customer Service Representative
Anthem Blue Cross
01.2008 - 01.2022
- Contributed valuable insights during policy development meetings, integrating an expert understanding of industry regulations into organizational policy changes.
- Mentored new team members on departmental protocols and best practices, fostering a positive learning environment within the team.
- Reviewed, analyzed and processed non-complex grievances and appeals.
- Leveraged data analysis tools to track performance metrics, identifying trends in case outcomes that informed strategic decision-making efforts.
- Streamlined workflows for faster decision-making, evaluating medical records and other documentation to support appeals decisions.
- Managed a high volume of cases, prioritizing tasks effectively and meeting strict deadlines for appeals resolutions.
- Managed a high volume of calls daily, maintaining composure under pressure while providing exceptional service.
- Actively listened to customers, handled concerns quickly and escalated major issues to supervisor.
- Demonstrated excellent multitasking abilities by simultaneously handling multiple tasks such as navigating systems, taking notes on calls, and answering inquiries from clients.
- Helped large volume of customers every day with positive attitude and focus on customer satisfaction.
- Managed high-stress situations effectively, maintaining professionalism under pressure while resolving disputes or conflicts.
- Resolved customer complaints with empathy, resulting in increased loyalty and repeat business.
- Handled escalated calls efficiently, finding satisfactory resolutions for both customers and the company alike.
Customer Service/ Order Entry
Parker House
03.2006 - 10.2007
- Troubleshooting of purchase orders to track missing deliveries
- Received high volume calls and placed follow up telephone calls/emails to answer customer questions and inquiries regarding shipments
- Opened new credit accounts which entailed faxing over credit reference request to check credit history
- Data Entry of 30-40 faxed orders into ACCPAC system in a timely manner
- Back up for the receptionist
Education
Completed coursework - Business Administration
Citrus College
08.1991
Skills
- Troubleshooting
- Organizational skills
- Microsoft Outlook
- Microsoft Word
- Excel
- Research
- Problem solving
- Account Management
- Time Management
- Client relations
- Case evaluation
- Verbal communication
- Policy interpretation
Accomplishments
- Used Microsoft Excel to develop inventory tracking spreadsheets.
- Achieved meeting production by completing 30 plus cases per week with accuracy and efficiency.
Timeline
Grievances & Appeals Analyst
Anthem Blue Cross
01.2022 - Current
Customer Service Representative
Anthem Blue Cross
01.2008 - 01.2022
Customer Service/ Order Entry
Parker House
03.2006 - 10.2007
Completed coursework - Business Administration
Citrus College
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