Kristi Jefferies
Graham,NC
Summary
Detail-oriented team player with strong organizational skills. Ability to handle multiple projects simultaneously with a high degree of accuracy. Analytical thinker skilled at developing innovative solutions to complex problems and effectively communication the end result via written or oral presentation.
Overview
18
18
years of professional experience
1
1
Certification
Work History
Sr Onsite Provider Operations Specialist
Blue Cross NC
06.2017 - Current
- Build a positive relationship with the provider community by allowing one on one contact to resolve issues and concerns.
- Act as a liaison between BCBSNC and all partner BCBS Health Care Plans to ensure timely end to end resolution of issues for all claims in accordance with the Inter-Plan Program (IPP) requirements. Interact effectively with BCBSNC staff, Providers, Partner Plans and any stakeholders involved with the onsite experience to include both internal and external Senior Level Management.
- Support the Provider Service Advisor and Strategic Relationship Consultant with education, root cause analysis and escalated issue resolution.
- Effectively manage inventory to meet departmental goals and the Service Level Agreements (SLAs) for all onsite providers.
- Utilize probing and problem solving methods to resolve all provider inquiries (via inbound calls, written or in person inquiries) on first contact. Document corrective measures and provide instructions as needed to internal business areas to ensure prompt resolution and response to customer inquiries.
- Recognize patterns of inconsistent and/or inaccurate claims filing practices and educate customers and providers on acceptable BCBSNC practices and policies.
- Identify and document system problems, gaps or inconsistencies in workflows, and/or processes; recommend updates, alternatives and/or solutions.
- Provide customer/provider additional education by presentation of information, administrative policies/procedures, systems, etc. on an as needed basis.
Sr. Claims Specialist
Blue Cross NC
06.2010 - 06.2017
- Serve as a subject matter expert for employees’ inquiries around work process, procedures, products, policies, etc.
- Process variety of customer transactions that may include non-routine suspended claims, inquiries, adjustments, and correspondence for any business segment
- Contribute in sessions to discuss claims processing workflow and make improvement suggestion to speed up overall claims quality and lead time
- Identify problems, gaps or inconsistencies in workflows and processes; recommend updates, alternatives and/or solutions
- Assist training team in development of claims production staff to be customer centric, cross functional, data driven personnel
- Support Provider Services in resolving immediate issues directly impacting provider financial well being
- Serve as subject matter expert for project, testing, and validation of claims work processes and procedures
- Communicate with Customer Service and Provider Services to understand key focus of service segment
- Act as a point of contact for NCQA and NCDOI for compliance
- Act as a point of contact for internal and/or external audits and projects as necessary; assist in planning, scoping, testing, training and implementation.
- Identify and document escalated, recurring or complex system and process problems. Interface with project teams to resolve these complex issues
Customer Service Representative
Blue Cross NC
03.2006 - 06.2010
- Utilize probing and creative problem solving methods to resolve customer inquiries on first contact. Document corrective measures and provide instructions as needed to internal business areas to ensure prompt resolution and response to customer inquiries.
- Recognize patterns of inconsistent and/or inaccurate claims filing practices among customers and providers, educate customers and providers on acceptable BCBSNC practices and policies.
- Successfully able to understand and communicate complex concepts to members, providers and colleagues in verbal and written form.
- Successfully utilizes added knowledge of product types, functional and/or technical skills to provide solution focused service to our customers on more complex insurance questions and issues.
- Ensures final disposition of each inquiry in a timely manner.
Education
Certification - Medical Office Administration
Alamance Community College
Graham, NCSkills
Problem solving
Time management
Critical thinking
Problem solving
Communication
Team player
Customer focused
Advanced oral and written communication skills
Certification
CPC-A, AAPC - Dec 2023
Timeline
Sr Onsite Provider Operations Specialist
Blue Cross NC
06.2017 - Current
Sr. Claims Specialist
Blue Cross NC
06.2010 - 06.2017
Customer Service Representative
Blue Cross NC
03.2006 - 06.2010
Certification - Medical Office Administration
Alamance Community College
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