Kiara Franklin
Hampton,VA
Summary
Compassionate Healthcare Specialist with over 14 years of experience in enhancing patient satisfaction, optimizing case management, and fostering positive patient experiences. Demonstrated expertise in conflict resolution, patient advocacy, and protecting health information privacy. Skilled in effective communication, problem-solving, and interdisciplinary collaboration to ensure the highest level of care and service. Proven ability to drive patient-centered practices and contribute to organizational goals within dynamic healthcare environments.
Overview
8
8
years of professional experience
Work History
Customer Service Representative
BCforward
Remote, VA
09.2024 - 03.2025
- Provide exceptional customer service by responding to inbound calls and addressing inquiries related to BCBS dental insurance plans, coverage, claims, and benefits.
- Process and resolve claims inquiries by reviewing patient information, verifying benefits, and troubleshooting discrepancies to ensure accurate and timely claim resolutions.
- Guide members through dental insurance benefits by explaining plan options, coverage limits, and claim processes in a clear, professional manner.
- Assist with the enrollment process for new and existing members, ensuring accurate entry of personal and coverage details, while adhering to company policies.
- Maintain detailed records of customer interactions, including inquiries, complaints, and resolutions, using BCBS systems to track and monitor case statuses.
- Collaborate with internal teams, such as claims processing, billing, and provider relations, to ensure a seamless member experience and timely issue resolution.
- Handle escalated inquiries and complaints, providing prompt and effective solutions while maintaining a high level of professionalism and customer satisfaction.
- Stay current with BCBS dental insurance policies and industry regulations, ensuring compliance, and providing accurate, up-to-date information to members and providers.
Eligibility Specialist I
GetixHealth
Remote, VA
11.2023 - 11.2024
- Maintain the appropriate level of work activity according to work standards and establish work processes to ensure timely certification for eligibility programs.
- Retrieve and forward requested records and information, including medical records, insurance policy information, remittance advice, and itemized statements, to appropriate parties.
- Analyze, distribute, and follow-up on special requests and adjustments with hospital personnel.
- Maintain consistent proactive communication with the patient or patient representative throughout the eligibility process, keeping the patient informed of the account progress.
- Screen patients and/or patient representatives to determine potential eligibility for Third Party resources.
- Communicate effectively with physicians, case managers, social workers, and hospital business office staff on a daily basis to ensure questions are answered and issues are addressed.
- Educate patients and patient representatives of the eligibility requirements, application process, and verification requirements for applicable programs.
- Maintain a professional relationship with the patient and governmental agencies to ensure cooperation and compliance.
- Document pertinent patient information and all work activity in the appropriate systems dictated by company policies and procedures.
Utilization Management Support Specialist
Apple One - Anthem Health Services
Virginia Beach, VA
01.2021 - 09.2021
- Provides non-clinical support to workflows involving utilization management.
- Performs outreach contact to providers and written notification to providers and members for initial determinations.
- Consults with internal departments to ensure cases meet guidelines.
- Researches cases referred to peer review and contacts the facility to schedule a physician-to-physician review.
- Documents task completion in applicable internal systems.
- Maintains the integrity of the company relationship with stakeholders by researching and responding to provider needs.
- Identifies risk situations and escalates to supervisor as appropriate.
- Achieves and maintains department and individual performance standards.
- Prepares administrative, approval and clinical denial letters as assigned.
- Reviews completed denial letters to ensure accuracy, template use and within the appropriate grade level.
- Troubleshoots issues noted on letters by coordinating with team members and physicians to ensure clear and accurate letters.
- Completes data validation for data entry on letters (address, dates, and other fields as applicable).
Clinical Appeals
WPS Health Solutions
Hampton, VA
07.2017 - 09.2021
- Worked closely with internal teams such as Medical Directors, Customer Service Representatives, and Provider Relations staff in order to facilitate successful resolution of appealed claims.
- Reviewed appeals submitted by patients and providers to ensure accuracy and compliance with policies.
- Collaborated with provider relations staff to resolve disputes between providers and health plans concerning payment for services rendered.
- Researched complex cases involving multiple parties or multiple issues to provide accurate decisions on appeals.
- Contacting insurance plans to determine the reasons claims were denied, analyzing the claims, and determining if appeal is necessary.
- Preparing the appeal materials which may include correcting and resubmitting claims, gathering additional information and including reviews of medical records.
- Acting as a liaison between healthcare providers for any additional medical documentation or clarification and submitting appeals in a timely manner.
- Work closely with the Case Management Department and HIM Department to ensure denial trends and outcomes are communicated in a timely man
Education
High School Diploma -
Hampton High School
Hampton05-2010
Skills
- Medical Terminology
- Claims Processing
- Basic ICD/CPT Coding
- EPIC, Meditech, Cerner
- HIPAA Compliance
- Inbound Calls
- Data Analysis
- Audit Skills
- Outbound Calls
- Prior Authorizations
- Eligibility Verification
- Microsoft Office Suite (Word, Excel, Outlook)
- Insurance Policies
- Data Entry
- Data Integration
- Patient Referrals
- Pharmacy Management Software (McKesson)
- Pharmacy Billing
- Workflow Optimization
- Insurance Plan Knowledge (PPO, HMO etc)
- Benefit Structures
- Claims Adjudication
- Account Reconciliation
- Electronic Health Records (EHR)
- State and Federal Regulations
- Claims Appeal Management
Timeline
Customer Service Representative
BCforward
09.2024 - 03.2025
Eligibility Specialist I
GetixHealth
11.2023 - 11.2024
Utilization Management Support Specialist
Apple One - Anthem Health Services
01.2021 - 09.2021
Clinical Appeals
WPS Health Solutions
07.2017 - 09.2021
High School Diploma -
Hampton High School