Karen Williams
Valley Springs,CA
Summary
Experienced HPSJ Claims Adjustment and Dispute Specialist with 4 years of high-accuracy work, consistently exceeding production expectations. In depth knowledge of HPSJ systems for efficient claims processing. Exceptional organization skills and ability to prioritize diverse tasks.
Overview
25
25
years of professional experience
Work History
Claims Adjustment and Dispute Specialist
HPSJ
French Camp, CA
09.2023 - Current
- Responsible for researching, resolving, and completing disputes, corrected claims, adjustment requests, and other tasks related to general claim processing.
- Provide feedback and/or compile and submit reports in a timely and accurate manner.
- Collaborates effectively with internal and external stakeholders.
- Identify claim error patterns and trends, document and escalate.
- Consistently met and surpassed service level targets.
- Excel in verbal and written communication.
- Ensured compliance with relevant regulations and contractual obligations.
- Effectively manages time to enhance productivity.
- Handle confidential information with appropriate discretion.
Claims Analyst
HPSJ
French Camp, CA
10.2020 - 09.2023
- Review claims data for accuracy and completeness.
- Research and analyze issues and errors to correctly identify cause.
- Interpret guidelines, regulatory requirements, contractual agreements and other related documentation as they pertain to the services provided by the unit.
- Approve or deny claims and send required correspondence based on processing guidelines and production standards.
- Identify error patterns and trends; document and escalate.
- Consistently achieve or exceed service levels across all work types each month.
Individual Family Plan Team Lead
Blue Shield Of California
Lodi, CA
07.2011 - 07.2020
- Manage team production and quality, ensuring all cycle time and quality goals are achieved.
- Manage new and existing inventory and create daily game plan for team members.
- Interpret guidelines, regulatory requirements, contractual agreements and other related documentation as they pertain to the services provided by the unit.
- Leadership responsibilities include interviewing and training staff, planning, assigning, and directing work; appraising performance; rewarding and counseling employees.
- Address complaints and resolve problems for Brokers, Customer Care, and Producer Services.
- Create and maintain Desk Level Procedural documentation.
- Responsible for handling system issues that are complex in nature.
- Encourage training and growth in all team members and continually challenges them to exceed their goals.
- Promote Engagement on the Team by seeking and leading Engagement Activities.
- Consistently achieve or exceed service levels across all work types each month.
- Support other areas through the effective use of load balancing and cross training to ensure all teams are prepared to execute to a successful Open Enrollment.
Employer Group Member Level Team Lead
Blue Shield Of California
Lodi, CA
01.2003 - 07.2011
- Manage team production and quality, ensuring all cycle time and quality goals are achieved.
- Manage new and existing inventory and create daily game plan for team members.
- Create and maintain Desk Level Procedural documentation.
- Mentor and train new and existing team members.
- Prioritize escalated Sales requests to ensure members have access to care.
- Review and approve enrollments that are outside of normal guidelines.
Member Level Processor
Blue Shield Of California
Lodi, CA
03.2000 - 01.2003
- Determine member eligibility and enroll into system for access to care.
- Serve as a mentor to other team members.
- Primary contact for Sales and Brokers needing assistance with access to care enrollments.
- Assign and distribute work assignments to team members in order to ensure goals are met.
Education
High School Diploma -
Galt High School
Galt, CASkills
- Microsoft Office
- Data Entry
- Attention to detail
- Teamwork
- Adaptability
- Dependable and reliable
Timeline
Claims Adjustment and Dispute Specialist
HPSJ
09.2023 - Current
Claims Analyst
HPSJ
10.2020 - 09.2023
Individual Family Plan Team Lead
Blue Shield Of California
07.2011 - 07.2020
Employer Group Member Level Team Lead
Blue Shield Of California
01.2003 - 07.2011
Member Level Processor
Blue Shield Of California
03.2000 - 01.2003
High School Diploma -
Galt High School
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