KIMBERLY HAM
Durham,NC
Summary
Seasoned professional with more than twenty years of experience in the insurance field. Equipped with strong problem-solving abilities, willingness to learn, and excellent communication skills. Poised to contribute to team success and achieve positive results. Ready to tackle new challenges and advance organizational objectives with dedication and enthusiasm.
Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.
Overview
24
24
years of professional experience
Work History
Fraud Investigations Associate
Blue Cross Blue Shield of NC
12.2023 - Current
- Assist in timely, thorough, and accurate investigations of suspected fraud and abuse claim cases.
- Effectively communicate change and updates on new procedures or problems.
- Responsible for working queues and claim types via Facets, State, Amisys and CSI's.
- Act as a point of contact for training cases.
- Monitor and identify claims submitted by providers under review.
- Manage daily aging reports and workflow process to reduce aging inventories.
- Develop DTP (dest top procedures) for Fraud claim process.
- Responsible for working Fraud email escalations mailbox, handling aged inquiries and escalations.
- Maintain index goals set by Blue Cross.
- Identify problems and trends, determined root cause through analysis and provide findings.
Medicare Secondary Payor MSP Specialist
Blue Cross Blue Shield of NC
03.2023 - 12.2023
- Responsible for the resolution of Medicare Secondary Payor demand letters issued by the Center for Medicare/Medicaid Services (CMS) and related inquiries from the Department of Treasury or its collection agencies.
- Deal directly with group administrators, legal department, the federal government, and its vendors as well as outside attorneys.
- Review and provide initial response to MSP demands within Federal mandated timeframe.
- Document all transactions related to each federal case in the MSP tracking database.
- Place phone calls to the US Department of Treasury, the Medicare Secondary Payor Recovery (MSPRC) or collection agencies to expedite review or resolve issues.
- Work directly with group administrators to provide detail status on all demand issues and obtain information necessary to respond to MSP demands.
- Write correspondence to the MSPRC, US Department of Treasury and/or collection agencies to provide a defensive response to demands.
- Accountable for the full resolution of the demand, including claims research, documentation, claim adjustments and issue special checks.
DOCUMENT OPERATIONS SPECIALIST/SME Front-End Claims
Blue Cross Blue Shield of NC
01.2004 - 03.2023
- Provide one-one-one training to ensure 100% accuracy rate.
- Effectively communicate change and updates on new procedures or problems.
- Vendor Source HOV/Exela 300-500 audits monthly.
- Accountable for manual and system 100-200 audits on team members monthly.
- Communicate positive feedback and documentation to team members and management.
- Provide subject matter expertise on the process flow and procedures to team members.
- Peer contact to resolve escalations and DOI complaints.
- Manage and distribute morning reports and audit spreadsheet.
- Manage daily aging reports and workflow process to reduce aging inventories.
- Develop job aides for claim process procedures.
- Assist in processing IPD, MHS and Legacy claims in the Formware OCR scanner system.
- Maintain index goals set by Blue Cross.
- Support IDC.
- Support production moves and testing.
STATE CLAIMS PROFESSIONAL
Blue Cross Blue Shield of NC
11.2010 - 11.2013
- Process claims averaging 99% accuracy annually.
- Process Power MHS, Max-MC, Envision and IPD utilizing online job aides and Microsoft Office.
- Identify system issues throughout different lines of business to resolve issues.
- Work closely to ensure that all claims are processed within the company calendar days of 95%.
- Process High dollar including Medicaid, 7D, 9R that are special rates due to reformed healthcare and special negotiated contracts in lines of the State Health Plan Contract.
- Communicate with providers and members regarding issues of delayed claims.
- Participate in company shadowing to ensure correct process through each department.
- Member of State Peer-Leadership-Team to bridge the gaps across company guidelines.
SME FRONT END SPECIALIST
Blue Cross Blue Shield of NC
01.2001 - 11.2004
- Respond promptly and accurately to Siebel (Service First) and Ansir inquiries.
- Provide backend support researching claim numbers on Power MHS, CMID, Magic, LRSP, and Doc Request.
- Correct system and personal aide errors for front and back end suspends (BlueCard, Local, Medicare, Dental, and New Blue).
- Process various health insurance claims (PRN, Office Visits, Dental, BlueCard, New Blue, Legacy, Medicare, BSEOB and UB).
- Process hospital accommodation rates according to BCBSNC hospital contracts.
- Research and key in the ACS reports.
- Key and audit Mail-backs to ensure accuracy and eliminate any delay in processing the claim.
- Assist in training newly hired team members.
- Maintain and exceed inventories while achieving company goals.
Education
High School Diploma -
Plainfield High School
Plainfield, NJ06-1987
Skills
- Facets
- Nuxeo
- Blue2
- Bi-Portal
- Production support
- Conflict resolution
- New hire training
- Preparing reports
- Steno
- Macess
- Power
Personal Information
Title: Fraud Investigations Associate
Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.
Demonstrates strong analytical, communication, and teamwork skills, with proven ability to quickly adapt to new environments. Eager to contribute to team success and further develop professional skills. Brings positive attitude and commitment to continuous learning and growth.
Awards
- 2020 CEO EXCELLENCE AWARD, Going HAMM (Highly Anxious Making Moves)
- 2013 SPOT AWARD, Outstanding quality and exceeding company goals
- Prop Point Recognitions
Leadership And Professional Development
- LEAN Project 2021, Change Agent/Ambassador
- Knowledge Management Member, African-American Black Employee Network (AABEN), Women's Employee Network (WEN)
- Change Agent/Ambassador 2020
Timeline
Fraud Investigations Associate
Blue Cross Blue Shield of NC
12.2023 - Current
Medicare Secondary Payor MSP Specialist
Blue Cross Blue Shield of NC
03.2023 - 12.2023
STATE CLAIMS PROFESSIONAL
Blue Cross Blue Shield of NC
11.2010 - 11.2013
DOCUMENT OPERATIONS SPECIALIST/SME Front-End Claims
Blue Cross Blue Shield of NC
01.2004 - 03.2023
SME FRONT END SPECIALIST
Blue Cross Blue Shield of NC
01.2001 - 11.2004
High School Diploma -
Plainfield High School
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