Helen Simmons
San Angelo,TX
Summary
I have been working in the health insurance industry for approximately 7 years. I have a thorough knowledge of how health insurance works and how benefits should apply. I am very detailed oriented and work well on my own or in a group. I am flexible and adapt quickly to change in procedures and policies. I am dedicated to learning and developing my skill set in order to be as knowledgeable and proficient as possible in any position that I hold.I am open, honest, and not afraid to ask questions when needed in order to have a better understanding of how something should be done.
Overview
8
8
years of professional experience
Work History
Senior Claims Specialist
Health Care Service Corporation, (BCBSTX)
11.2023 - Current
- In this role I perform all the duties that I did in my previous position of Quality coach.
- I also support the Quality coaches in their job by answering their questions on complex audits through tech time.
- I review and audit the quality coaches audits that they submit to determine if they are done correctly.
- I facilitate any one-on-one time that may be needed with the Qc's or claims operators to further clarify an audit or claim situation as needed.
- Part of my role includes helping during training sessions for the New QC's
- I attend group quality meetings to help determine trending errors for front line staff and give input on any up-skilling that is suggested to improve the overall quality accuracy for the company.
- I work closely with the quality coordinators to determine any existing discrepancies in procedure flows or learning materials to clarify and validate the information being given you front line staff.
- I specialize in group policies that have specific processing needs.
- I support staff on audits that have high priority such as high dollar claims and prompt pay claims in order to avoid penalties.
- I am cross trained in many lines of business which include PPO,ASO,HMO, prompt pay claim denial, pre payment review, DRG, and specialized groups such as UT,Baylor, student health, TRS, and ERS and often get pulled to help on those when the need arises.
Quality coach
HCSC BCBS
12.2019 - 11.2023
- As a claims quality coach I am responsible for auditing previously processed claims to ensure they were adjudicated correctly
- I work with several lines of business such as ASO/PPO/Texas prompt pay/ HMO, and groups that require special processing
- This also included auditing high dollar claims and other claims that could potentially have a high impact on the company.
- I audit everyone from new employees all the way up to the Vice President of payment services.
- I set up meetings with operators who would like additional feed back on their audited claims in order to give direction on how to avoid future errors and findings and to give instruction on procedures and insights that may have been missed during processing.
- This role is dedicated to identifying and correcting errors made during claims processing in order to ensure prompt and accurate processing of claims so that we serve our members and providers in the best way possible.
Sr claims tech
Blue Cross Blue Shield
San Angelo, TX
07.2018 - 12.2019
- Sr tech claims examiner in this role I worked on complex claims that required a higher level of training
- I learned how to manually calculate to apply the appropriate benefits
- high dollar claims, prompt pay claims, air ambulance, and VIP locks among others.
Claims technician
Blue Cross Blue Shield
12.2016 - 12.2019
- Claims techClaims Technician
- As a claims tech I worked less complex claims and ensured that they were paid/denied in a timely manner.
- I began training on group policies that required specialized processing.
- My focus was on prompt pay claims which are required to be processed within a limited time frame to avoid penalties and to satisfy our agreement with the group policies (companies) the claims are being worked for.
- I began learning and developing my skill set in this position to be highly detail oriented, complete thorough investigation into the claims being worked to ensure that the claims were being processed with accuracy to avoid penalties and to satisfy our timeframe for claim release and payment.
CSR
Sitel
08.2016 - 11.2016
- Take inbound calls for electric company
- Make payment arrangements for customers
- Explain high Bills
- Offer energy saving advice to customers issue reconnect quotes and reconnect customers after payment has been made.
Education
High School Diploma - General
University High
Roswell, NM01.1996
Skills
- Customer Service Skills (10 years)
- Computer literate (10 years)
- Cash control (10 years)
- Auditing
- Problem-solving
- Flexibility
- Team Work
- Reliability
- QA/QC
- Insurance policy knowledge
- Investigative abilities
- Regulatory Awareness
- Claims Investigation
- Written and Verbal Communication
- Claims Processing
- Microsoft Office
- Documentation Review
- Critical Thinking
- Team Collaboration
- Active Listening
- Decision-Making
- Relationship Building
- Insurance policy coverage knowledge
- Claims Evaluation
- Claims adjustment
- Coaching and Mentoring
- Coverage Determination
- Payment Processing
- Liability Determination
- Team Training
- Denied claims identification
- Records Review
- Policy investigations
- Benefits review
- Healthcare Common Procedures Coding System (HCPCS)
Additional Information
I am always willing to learn a new skill and looking for new ways to expand my knowledge. I am trustworthy, honest, and dependable. I show up to work on time and ready to work. I work well with others as well as on my own. I have been working with HCSC since 2016 and have a solid understanding of health insurance claims, processing, benefits, and auditing of those claims. I have working knowledge of complex claims and have been working in quality for 5 years. This job includes auditing processed claims to ensure that they have been worked accurately and completely per our corporate procedures and policies to best serve our members and providers efficiently. I work with several different programs such as AIM, EVIVORE, ARIS, Prime Therapeutics, and many others on adaily basis. I am now working as direct support staff to QC's as a senior claim's specialist. I am looking forward to continuing my career in the health insurance industry. Thank you.
Timeline
Senior Claims Specialist
Health Care Service Corporation, (BCBSTX)
11.2023 - Current
Quality coach
HCSC BCBS
12.2019 - 11.2023
Sr claims tech
Blue Cross Blue Shield
07.2018 - 12.2019
Claims technician
Blue Cross Blue Shield
12.2016 - 12.2019
CSR
Sitel
08.2016 - 11.2016
High School Diploma - General
University High