Kimberly Coffman
Saint Clair,MI
Summary
Detail-oriented individual with exceptional customer service and analytical skills. Proven ability to handle multiple tasks effectively and efficiently in fast-paced environments. Known for adapting to changing needs and ensuring reliability. Demonstrates exceptional track records based on solid performance to ensure the success and achievement of goals.
Overview
10
10
years of professional experience
Work History
Pricer VII
Blue Cross Blue Shield of MI
07.2023 - Current
- Advanced claims adjudication position which requires reviewing and processing original claims and adjustments for facility claims
- Evaluate various claim edits, including but not limited to resolving edits for eligibility, benefits, member liability/cost share, pricing and authorization/referrals for diverse products and benefit categories, according to corporate and departmental policies, procedures and other guidelines while adhering to quality and productivity standards
- Handle inquiries generated from internal and external sources including vendor partners and adjust claims as appropriate based on nature of the inquiry
- Contact internal resources via phone or written communication for additional information required to process claim payments
- Assists Instate Claims Operations with working open inventory of claims in Navigator
- Work consistently with Nasco 3270 and NCompass
- Utilize Electronic Claims data - 835/837 files
Grievance and Appeals Coordinator
Blue Cross Blue Shield of Michigan
08.2017 - 07.2023
- Process appeals, grievances and organization determination cases in accordance with Centers for Medicare and Medicaid Services
- Communicate with Medicare Advantage members, member representatives and providers to obtain and offer pertinent case information
- Research complex claims, analyze documentation and make decisions to process claims for payment or uphold denial based on Medicare guidelines
- Analyze and resolve complaints in the best interest of the member while adhering to Federal regulations
- Prepare pre-service determination packets for Medical Directors by collecting members protected health information such as medical diagnosis, medical records and plan of care
- Assist Medical Directors throughout the pre-service determination process by communicating with members, member representatives or providers for additional information
- Responds to and finalizes confidential cases
- Adheres to the strictest of time frames for urgent and non-urgent requests as imposed by the various federal and state laws
Help Desk Support Representative
Blue Cross Blue Shield of Michigan
06.2016 - 08.2017
- Assisted Customer Service Representatives with unusual or complex inquiries, including irate calls
- Analyzed, evaluated, resolved and responded to United Auto Workers Benefit Representatives, Medicare Advantage Members, and Provider inquiries
- Worked more complex and sensitive inquiries which demanded a higher level of knowledge and skill
- Provided accurate detailed information following Centers for Medicare and Medicaid Services and company guidelines
Customer Service Representative and Claims Specialist
Blue Cross Blue Shield of Michigan
08.2014 - 06.2016
- Serviced Medicare Advantage members including Michigan Public School retirees, United Auto Worker retirees, individual members, member representatives and providers with the following:
- Conducted research and resolved inquiries relating to medical, dental and prescription drug claims
- Assisted with a wide variety of enrollment inquiries
- Explained covered medical, dental and prescription drug benefits
- Educated members and providers on organization determination and prior authorization process
- Educated members on grievance and appeals process
Education
ASSOCIATE DEGREE - EDUCATION MATHEMATICS
Macomb Community College
Macomb, MichiganSkills
- Teamwork
- Analytical skills
- Research
- Problem resolution
- Decision making
- Time management
- Regulatory compliance
- Microsoft Office
- Word
- Nasco / 3270
- NCompass
- Ika
Timeline
Pricer VII
Blue Cross Blue Shield of MI
07.2023 - Current
Grievance and Appeals Coordinator
Blue Cross Blue Shield of Michigan
08.2017 - 07.2023
Help Desk Support Representative
Blue Cross Blue Shield of Michigan
06.2016 - 08.2017
Customer Service Representative and Claims Specialist
Blue Cross Blue Shield of Michigan
08.2014 - 06.2016
ASSOCIATE DEGREE - EDUCATION MATHEMATICS
Macomb Community College
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