Jennifer Reid

• Keep current with all policies, procedures and regulatory guidelines to effectively interpret requirements as related to the resolution of provider disputes.
• Review, analyze and process routine and more complex provider disputes, requiring a more in-depth understanding of appropriate payment or denial practices, benefits, policies and procedures, and contract interpretation.
• Identified insurance coverage limitations with thorough examinations of claims documentation and related records in multiple systems.
• Researched claims and incident information to deliver solutions and resolve problems.
• Generate appropriate/accurate resolution letters and document all relative findings and actions in all applicable systems.

• Demonstrate concierge service to high profile groups
• Handle a high volume of inbound/outbound calls and member correspondence within a dynamic call center environment
• Act as member advocate, making outbound calls to providers, vendors and medical groups on behalf of the member
• Resolve and educate incoming calls concerning claims, authorizations, eligibility, benefits, co-pays, provider information and pharmacy needs for PPO. POS and HMO plan members
• Ability to coordinate with other departments within Blue Shield in a professional manner to provide the highest level of customer satisfaction to resolve inquiries on the first call
• Dual OPS Facets/Legacy Claims representative tasked with the duties of taking care of member inquiries verbal and written in regards to claims and benefits and resolving any member concerns
• Research and coordinate adjustments to claims, medical groups, and memberships
• Elevate level of empowerment to resolve disputes prior to escalating to appeals and grievances
• Draft statements to summarize procedures, payments and underlying policy coverage
• Utilize available programs, review CMS-1500 forms, CPT, HCPC, ICD-9 and ICD-10 codes to verify the validity of claims prior to adjusting
• In depth computer literacy and navigation skills within the various systems utilized by Blue Shield of California to assist with member inquiries

Positions Held

:

• 11/2018 - 01/2018 CO-Trainer for Eligibility and Benefits
• 01/2018 - 04/30/2018 Interim Lead

• Managed 3 offices, 8 doctors and 6 direct employees
• Ensured patient satisfaction - over 40,000 patients
• Selected, developed and retained qualified staff
• Trained, educated and coached all new staff
• Evaluated employee performance, provided feedback to increase staff productivity
• Consistently met monthly prescription quotas
• Administered and created scheduling templates for all clinics and doctors for routine exams, medical visits and vision therapy
• Maintained and coordinated calendars for doctors and staff vacation and day-to-day meetings
• Reviewed and approved time cards for all employees
• Served as liaison between management, staff and the community for vision therapy