Kathleen Moore
Lewiston,Idaho
Summary
Organized and dependable candidate successful at managing multiple priorities with a positive attitude, and a high degree of accuracy. Willingness to take on added responsibilities to meet team goals. Exceptional interpersonal and problem-solving skills. Detail-oriented team player with strong organizational skills, and excellent time management. Able to provide thorough investigative research into complicated and specialized claims overpayment issues.
Overview
21
21
years of professional experience
Work History
Claims Investigation Analyst II
Cambia
12.2021 - Current
- Makes informed decisions regarding the disposition of claims; may include payment or denial of claims, or requests for further information for all lines of business within Cambia.
- Identified trends and patterns in large datasets, leading to actionable insights for business growth.
- Enhanced team collaboration by providing clear communication of complex findings
- Perform at a high-level to ensure quality standards.
- Comply with MTM and Consortium standards as they relate to meet BCBSA standards and corporate goals.
- Assisted in decision-making processes by presenting accurate, data-driven recommendations.
- Update and assist in developing documentation for claim processing.
- Manages Facets tasks workflow.
- Deep research on possible new concepts submitted by vendors.
Performance Integrity Analyst
Cambia
01.2014 - 11.2021
- Examine and validate plan and employee performance according to the established policies, procedures and audit guidelines.
- Monitor the accuracy and timeliness of claims, membership and customer service to meet performance and service goal levels.
- Provides reports and feedback for quality improvement to management.
- Checked claims coding for accuracy with ICD-10 standards.
- Runs daily reports needed for audit.
Multi Service Specialist
Cambia
11.2009 - 02.2012
- Developed strong client relationships through consistent communication and attentive service.
- Responded promptly to customers' concerns and coordinated swift resolutions to handle service issues.
- Tracked customer support cases and followed up on complex issues to correct problems.
- De-escalated problematic customer concerns, maintaining calm, friendly demeanor.
- Documented conversations with customers to track requests, problems and solutions.
- Upheld strict quality control policies and procedures during customer interactions.
- Provided outstanding service to new and long-standing customers by attending closely to concerns and developing solutions.
Customer Service Professional
Cambia
07.2006 - 01.2008
- Enhanced customer satisfaction by addressing and resolving complaints promptly and professionally.
- Streamlined call center operations for improved efficiency and reduced wait times.
- Documented conversations with customers to track requests, problems and solutions.
- Met and exceeded productivity targets by handling every interaction with top-notch customer service.
- Assessed customer account information to determine current issues and potential solutions.
- Shared detailed information regarding options to help customers make decisions.
- De-escalated problematic customer concerns, maintaining calm, friendly demeanor.
Customer Service Manager
Walmart
06.2003 - 07.2006
- Increased team productivity by providing ongoing training and support to customer service employees.
- Managed the full front end of the store including all working cashiers, and money exchanges. Also supervised the CS Desk and those transactions.
- Investigated sensitive customer service complaints and delivered prompt resolution to customer satisfaction.
- Evaluated and authenticated returns, exchanges and voids.
- Interviewed, hired and trained new quality-focused customer service representatives.
- When help was needed, work would be done on the cash register, helping bag items and a number of other jobs.
Education
High School Diploma -
Charles Frances Adams High School
Clarkston, WA06.2003
Skills
- Trend Modeling
- Documentation and Reporting
- Report Preparation
- Audit Support
- Risk mitigation
- Working collaboratively
- Data management
- Analytical
- Transaction reviewing
- Fraud assessment
- Quality Control
- Manual processing
Timeline
Claims Investigation Analyst II
Cambia
12.2021 - Current
Performance Integrity Analyst
Cambia
01.2014 - 11.2021
Multi Service Specialist
Cambia
11.2009 - 02.2012
Customer Service Professional
Cambia
07.2006 - 01.2008
Customer Service Manager
Walmart
06.2003 - 07.2006
High School Diploma -
Charles Frances Adams High School
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