Karen McKee
Columbia,SC
Summary
Dedicated claims professional with strong organizational and decision-making skills. Experienced in reviewing claims for accuracy and maintaining effective customer relations. Committed to resolving complex inquiries and enhancing operational efficiency.
Overview
3
3
years of professional experience
Work History
Claims Representative II
Blue Cross & Blue Shield of SC
2024.11 - Current
- Processed claims efficiently while ensuring adherence to company policies and regulations.
- Reviewed claim submissions for accuracy, completeness, and eligibility requirements.
- Communicated with policyholders to clarify information and resolve inquiries promptly.
- Collaborated with healthcare providers to gather necessary documentation for claims processing.
- Ensures effective customer relations by responding accurately, timely, and courteously to telephone, written, web, or walk-in inquiries. Handles situations which may require adaptation of response or extensive research. Identifies incorrectly processed claims and processes adjustments and reprocessing actions according to department guidelines.
- Examines and processes claims and/or non-medical appeals according to business/contract regulations, internal standards and examining guidelines. Enters claims into the claim system after verification of correct coding of procedures and diagnosis codes. Ensures claims are processing according to established quality and production standards.
- Identifies complaints and inquiries of a complex level that cannot be resolved following desk procedures and guidelines and refers these to a lead or manager for resolution. Identifies and reports potential fraud and abuse situations.
Customer Service Representative I
Blue Cross Blue Shield of SC
2024.06 - 2024.11
- Ensure effective customer relations by responding accurately, timely, and courteously to telephone, written, web, or walk-in inquiries. Handles situations which may require adaptation of response or extensive research. Accurately documents inquiries.
- Initiate or processes adjustments or perform other research as needed to resolve inquiries. Coordinates with other departments to resolve problems. Responds to, research and/or assists with priority inquiries and special projects as required by management.
- Provide feedback to management regarding customer problems, questions and needs. Maintains accurate records on complaints and/or other customer comments and makes recommendations for changes to management. Follows through on complaints until resolved or reports to management as needed.
- Maintain basic knowledge of quality work instructions and company policies. Assists with process improvements through the recommendation of changes in procedures and techniques discovered during daily operations. Maintains all departmental productivity, quality, and timeliness standards.
- Assist with the training of new employees and cross training of coworkers.
Customer Service Representative
Blue Cross Blue Shield of SC
2023.10 - 2024.02
- Responds to written and/or telephone inquiries according to desk procedures, ensuring that contract standards and objectives for timeliness, productivity, and quality are met. Accurately documents inquiries. Identifies incorrectly processed claims and processes adjustments and reprocessing actions according to department guidelines.
- Examines and processes claims and/or non-medical appeals according to business/contract regulations, internal standards and examining guidelines. Enters claims into the claim system after verification of correct coding of procedures and diagnosis codes. Ensure claims are processed according to established quality and production standards.
- Identifies complaints and inquiries of a complex level that cannot be resolved following desk procedures and guidelines and refers these to a lead or manager for resolution. Identifies and promptly reports and/or refers suspected fraudulent activities and system errors to the appropriate departments.
Education
High School Diploma -
Johnsonville High School
Johnsonville1997-06
Skills
- Microsoft office
- Insurance claims review
- Claims investigation
- Time management
- Decision-making
- Excellent verbal and written communication skills
- Proficient spelling, punctuation, and grammar
- Organizational skills
- Ability to handle confidential or sensitive information with discretion
Timeline
Claims Representative II
Blue Cross & Blue Shield of SC
2024.11 - Current
Customer Service Representative I
Blue Cross Blue Shield of SC
2024.06 - 2024.11
Customer Service Representative
Blue Cross Blue Shield of SC
2023.10 - 2024.02
High School Diploma -
Johnsonville High School