Emylye Garaba

Processed appeals and grievances, analyzed, researched and provided comprehensive responses in accordance with established regulatory and accreditation guidelines as outlined by Centers for Medicare & Medicaid Services (CMS) and National Committee for Quality Assurance (NCQA) guidelines.

Contacted customers to gather information and communicate disposition of case.

Conducted pertinent research in order to evaluate, respond to, and finalize each case within the established timeliness guidelines.

Provided comprehensive appeals and grievance responses that support the plan decision and comply with regulatory and accreditation guidelines. Supported these decisions by referencing specific and applicable language from the plan documents such as the Evidence of Coverage, certificates, riders, and Summary of Benefit plan descriptions.

Maintained thorough knowledge of internal policies, procedures, and regulations for accurate resolution of appeals, complaints and grievances.

Provided accurate reporting of the types/volumes/causes of inquiries received in order to establish trends. Used these trends to work across the organization to develop plans of action against common issues affecting our members.

Identified business problems and initiated corrective measures to be reviewed by appropriate areas for corrective action by their leadership teams.

Developed a BCN Advantage specific post service appeal training program in order to better streamline our new hire training.

Served on a BCN Advantage work group to provide insight into the types of complaints and grievances being filed by our members regarding the yearly plan documents such as the Evidence of Coverage and Summary of Benefits.

Completed monthly audits of the Customer Service Representatives, reviewing a sample of phone calls for accuracy and completeness errors, HIPAA violations and Service Mentor performance.

Provided consistent and developmental feedback to employees through coaching and mentoring.

Made recommendations for solutions to deficiencies located in the audit process.

Assisted as a Subject Matter Expert in BCN Individual and Group benefits as well as the Medicare BCN Advantage lines of business. Focused on educating Customer Service Representatives how to analyze and interpret the Blue Care Network plan documents, certificates, riders, and summary of plan descriptions.

Facilitated weekly quality council meetings alongside the leadership and training departments to resolve evaluation disputes filed by Customer Service Representatives.

Assisted leadership as a subject matter expert in conducting Service Mentor calibrations monthly for each team.

Identified and compiled quality error data for review by the BCN leadership team.

Conducted structured side by side training for Customer Service Representatives on a formal discipline track.

Investigated, processed, resolved, and responded to member, provider or beneficiary inquiries received by telephone, mail, or in person, regarding benefits, eligibility, materials, ID cards, Primary Care Physician changes, and complex inquiries.

Investigated, analyzed, and directed claim related inquiries.

Educated new and existing customers on their BCN benefits as outlined in the plan documents, certificates, riders, and summary of plan descriptions.

Played integral role in meeting the departmental service level agreement with The University of Michigan.