Erica Cummings
Jacksonville,FL
Summary
Dynamic and results-oriented professional with extensive experience in claims management and customer service, notably at FLORIDA BLUE. Excelled in medical coding and de-escalation, enhancing customer satisfaction and operational efficiency. Proven track record in implementing strategic plans and leveraging SQL development skills to drive continuous improvement, achieving significant process enhancements.
Overview
10
10
years of professional experience
Work History
Medical Claims Examiner
FLORIDA BLUE
Jacksonville, FL
10.2021 - Current
- Ensures that all customers are warmly greeted, their needs are assessed quickly, and they are referred to the appropriate setting, person, information, or tools to address their needs
- Provides a customer-friendly service experience for customers with questions or issues related to health care, health insurance (benefits, claims, premium payments, membership, billing, and enrollment) or other related topics
- Uses web-based tools and other aids to facilitate and teach customers to use resources, tools, information, and products to manage their health care and health care costs most effectively
- Research and analyze production claims in order to identify systemic problems, claims processing issues and continuous improvement opportunities
- Coordinate, produce, and distribute business documents such as but not limited to cue cards, reports, system and process documentation
- Cross-promotes and identifies opportunities for members to participate in value added services and programs
- Experience developing and implementing strategic plans and reports
- Experience managing complex AR and complex claims
- Knowledge of MS Office applications including Word, PowerPoint, and Excel
- Assists with other ad hoc requests, such as planning and coordinating team events, coordinating meetings, creating meeting materials, and drafting communications
- Experience in preparing and presenting training materials
- Experience in negotiating and influencing customer outcomes
- Responsible for creating, maintaining & validating system documentation
- Possesses thorough knowledge of all relevant operational processes and procedures as well as company products and services
- Proficient in and able to navigate all important computer systems in order to pull reports, shadow clients, and troubleshoot technical issues
- Analyzed provider contracts to ensure proper reimbursement levels were achieved.
- Collaborated with internal departments such as billing, customer service, and IT.
- Developed various reports using SQL to monitor reconciliation processes.
Service Desk Analyst
MAYO CLINIC
Jacksonville, FL
02.2021 - 10.2021
- Responsible for independently creating and scheduling appointments within the electronic medical record for a complex, multispecialty medical practice
- Obtain and input initial demographics for inpatient and outpatient pre-certification
- Accurate documentation of information obtained
- Gathered patient-specific demographic and provider information to accurately assess the nature of the request and determine the appropriate appointment area; properly advised patients regarding the need for co-payments, referral authorizations, and/or pre-service deposits to ensure the patient arrived on time and was prepared for their procedure or visit; and collected all Guarantor and insurance details needed to help assess a patient’s eligibility
- Maintained a professional demeanor when interacting with a variety of individuals including patients, customers, referring physicians, Mayo providers, allied health staff, and family members
- Worked with several complex scheduling workflows, managing telephone calls, online requests, and/or fax requests
- Screen calls appropriately and work with clinicians to ensure optimal turnaround times
- Responsible for managing all clinical faxes and ensuring all regulatory timelines are met
- Must meet all regulatory and compliance requirements for Utilization Management
- Documented solutions and troubleshooting steps concisely in ticketing system and alerted other team members of new service solutions.
- Monitored incoming calls using ACD reports to ensure quality service delivery standards were met.
Customer Account Representative
WELLS FARGO
Jacksonville, FL
06.2020 - 02.2021
- Worked within a contact center environment to support financial products and services
- Identified opportunities to improve the customer service experience and offered ideas to resolve internal and external customer issues to provide first contact resolution
- Interacted with internal customers
- Performed moderately complex customer support tasks
- Managed risk by following all policies and procedures and staying abreast of changes to them
- Advocated for digital services such as online delivery of statements and other documents, eSign paperwork, and any other digital opportunities
AR Specialist/Claims Representative
MBB Radiology
Jacksonville, FL
05.2015 - 03.2020
- Responsible for facilitating referrals and/or prior authorizations and scheduling for interventional outpatient procedures in an efficient and timely manner
- Communicated with referring physicians, hospital personnel, and patients
- Coordinate, produce, and distribute business documents such as but not limited to cue cards, reports, system and process documentation
- Responded appropriately to constructive criticism from my assigned supervisor
- Serve as the primary resource and subject matter expert for new and underdeveloped Claims products & initiatives support for claims processing requiring special handing due to emergency or crisis level situations
- Research and analyze production claims in order to identify systemic problems, claims processing issues and continuous improvement opportunities
Education
High School Diploma -
East St. Louis Sr. High School
01.2006
Skills
- Billing and collections
- Medical coding/terminology
- Knowledge of Microsoft Office products
- Call Center
- De-escalation
- Ability to handle multiple projects and meet deadlines
- Pleasant and easy to understand voice
- Claims management
- Claims processing proficiency
- HIPAA compliance
- SQL development
- Data collection management
- ITIL expertise
- Asset management
- Policy enforcement
- Technical troubleshooting
References
References available upon request.
Timeline
Medical Claims Examiner
FLORIDA BLUE
10.2021 - Current
Service Desk Analyst
MAYO CLINIC
02.2021 - 10.2021
Customer Account Representative
WELLS FARGO
06.2020 - 02.2021
AR Specialist/Claims Representative
MBB Radiology
05.2015 - 03.2020
High School Diploma -
East St. Louis Sr. High School
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