Kimberly Coffman
Saint Clair
Summary
Resourceful professional with strong customer service and analytical skills. Skilled in managing multiple tasks in fast-paced environments while adapting to changing priorities. Committed to achieving goals and delivering reliable results. Motivated to embrace new challenges and leverage interpersonal strengths in collaborative settings.
Overview
12
12
years of professional experience
Work History
Analyst - Instate Claims Operations
Blue Cross Blue Shield of MI
Detroit
02.2025 - Current
- Results driven In-State Claims Operations Analyst with expertise in Medicare Advantage Claims Workflows, operational process improvement, and production analysis
- Proven ability to evaluate complex claims processes, develop workflow tools, and implement improvements that enhance processing efficiency and claim accuracy
- Led development of Medicare Advantage claims decision-tree tool, consolidating keying procedures into a single resource that improved processing consistency and reduced claim keying errors
- Known for translating operational data into actionable insights and sustainable process improvements that support quality, compliance, and service goals
- Developed and maintained operational tracking and reporting tools used to monitor claims inventory, aging claims, and workflow performance, helping leadership identify trends and prioritize workload
- Analyzed operational data to identify and contribute to continuous improvement initiatives that enhanced quality, compliance, and customer service outcomes
- Supported creation and rollout of training resources and e-learning modules to enhance staff understanding of claims procedures and ensure consistent processing practices across department
Pricer VII - Post Service Review
Blue Cross Blue Shield of MI
Detroit
07.2023 - 02.2025
- 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
- Resolved inquiries from internal and external sources, including vendor partners, resulting in timely adjustments to claims.
- Coordinated with internal resources through phone and written communication to gather information necessary for processing claim payments.
- Supported Instate Claims Operations by addressing open inventory of facility claims, contributing to streamlined processing.
- Utilized Nasco 3270 and NCompass systems to manage claims processing efficiently.
- Accessed Electronic Claims data, specifically 835 and 837 files, for claims processing.
Grievance and Appeals Coordinator
Blue Cross Blue Shield of Michigan
Detroit
08.2017 - 07.2023
- Processed appeals, grievances and organization determination cases in accordance with Centers for Medicare and Medicaid Services
- Communicated with Medicare Advantage members, representatives, and providers to gather and provide critical case information
- Researched complex claims and analyzed documentation to determine claim outcomes in compliance with Medicare guidelines
- Analyzed and resolved complaints in the best interest of the member while adhering to Federal regulations
- Compiled pre-service determination packets for Medical Directors by gathering members' protected health information, including medical diagnoses, records, and care plans
- Assisted Medical Directors throughout the pre-service determination process by communicating with members, member representatives or providers for additional information
- Responded to and finalized confidential cases
- Adhered to strict time frames for urgent and non-urgent requests set by federal and state laws
Help Desk Support Representative
Blue Cross Blue Shield of Michigan
Detroit
06.2016 - 08.2017
- Analyzed and resolved inquiries from United Auto Workers Benefit Representatives, Medicare Advantage Members, and providers, ensuring accurate and timely responses
- Handled sensitive inquiries requiring advanced knowledge and skills, contributing to improved customer satisfaction
- Provided accurate detailed information following Centers for Medicare and Medicaid Services and company guidelines
- Assisted customer service representatives with complex inquiries, enhancing resolution of irate calls
Customer Service Representative and Claims Specialist
Blue Cross Blue Shield of Michigan
Detroit
08.2014 - 06.2016
- Serviced Medicare Advantage members, including Michigan Public School and United Auto Worker retirees, individual members, representatives, and providers, addressing inquiries and providing support in benefits and claims processes.
- Conducted research and resolved inquiries relating to medical, dental and prescription drug claims
- Assisted with enrollment inquiries, ensuring members received accurate information and timely assistance to facilitate smooth enrollment.
- Explained medical, dental, and prescription drug benefits, clarifying coverage details to enhance member understanding and satisfaction.
- 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
- Operational analysis
- Quality assurance
- Process improvement
- Analytical skills
- Problem resolution
- Decision making
- Time management
- Research
Timeline
Analyst - Instate Claims Operations
Blue Cross Blue Shield of MI
02.2025 - Current
Pricer VII - Post Service Review
Blue Cross Blue Shield of MI
07.2023 - 02.2025
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