LaQuaanida Simmons
Spring Lake,NC
Summary
Qualified Claims Representative versed in investigating claims, verifying health benefits, verifying information and prior pharmacy experience. Friendly and upbeat team player with organized and disciplined approach. Offering 8 years of health insurance experience.
Overview
20
20
years of professional experience
Work History
Claims Representative
Blue Cross Blue Shield North Carolina
2024.04 - Current
- Process, adjust or update various routine claims payments and payment errors for singular business segment and/or claims-provider type
- Respond promptly and accurately to inquiries from Core Service, subscribers, providers, physicians, and other insurance carriers regarding claims payments
- Meet or exceed established quality and performance standards
- Determine suspended claim resolution methods by reviewing benefit eligibility, claims history and other information
- Identify system problems, including documentation of the issue, recommendation of potential solutions, referral to appropriate technical staff and follow-up to ensure resolution
- Assist management by identifying and analyzing opportunities for improvements in BCBSNC processes, policies, and services
- May coordinate with other insurance carriers and Medicare to determine BCBSNC payment liability
- Review claims for possible 'fraud and abuse' and send to Special Investigations Unit for additional investigation
- Performed as a SME and the implementation of the new production tool
- Worked productively in fast-moving work environment to process large volumes of claims.
- Maintained compliance with industry regulations by adhering to established procedures and guidelines in claims handling.
Group Services Representative
Blue Cross Blue Shield North Carolina
2019.09 - 2024.04
- Answer incoming phone calls from agents and groups and identify the type of assistance needed.
- Answered internal calls regarding benefits, eligibility, billing and payments, authorizations for treatment or prescription, explanation of benefits, and claims.
- Focus on resolving issues on the first call, navigating through complex computer systems to identify the status of the issue and provide appropriate response to agents or groups.
- Forwarded claims to appropriate departments for review and adjustment when claim denial errors are discovered.
- Complete the documentation necessary to track issues and facilitate the reporting of overall trends.
- Escalate unresolved issues to appropriate department.
- Collaborated with team members to ensure seamless delivery of group services.
- Provided exceptional customer support, addressing concerns promptly and professionally.
- Resolved complex issues with effective communication and problem-solving skills.
- Demonstrated adaptability through cross-training in various roles within the pharmacy setting to better serve customers as needed.
- Reviewed pharmacy claims in RX claims application, and verified prescriptions and pricing in Prime.
Patient Service Representative
Affordable Dentures & Implants
2019.05 - 2019.08
- Answer inbound calls from customers and provide accurate information in a professional manner
- Set appointments for patients with a high level of accuracy
- Escalate unresolved issues to appropriate department
- Build sustainable relationships with patients by taking an extra mile
- Provide patients with fees and services offered by each practice
- Handled sensitive patient concerns with professionalism and empathy, fostering an atmosphere of trust within the clinic.
- Handled customer service inquiries in person, via telephone and through email.
- Served as a reliable source of information for patients regarding appointment scheduling, insurance coverage inquiries, and general office policies.
Agent Services Representative (Contractor)
Blue Cross Blue Shield of NC
2018.12 - 2019.02
- Answer incoming phone calls from agents and identify the type of assistance needed
- Assisted agents with inquiries regarding health benefits, eligibility, billing and payments, authorizations for procedures, explanation of benefits, and claims
- Educated agents on their health benefits options, supporting informed decision-making during open enrollment periods
- Focus on resolving issues on the first call, navigating through complex computer systems to identify the status of the issue and provide appropriate response to caller
- (Facets, WebNow, Nuxeo, Agent Portal, Power, Service 1st, 834 Spreadsheet)
- Participated actively in regular team meetings aimed at driving continuous improvement initiatives across various aspects of agent services operations
- Forwarded claims to appropriate departments for review and adjustment when claim denial errors are discovered
- Deliver information and answer questions in a positive manner to facilitate strong relationships with provider agents
- Complete the documentation necessary to track issues and facilitate the reporting of overall trends
- Reviewed pharmacy claims in RX claims application, and verified prescriptions and pricing in Prime
Agent Services Representative (Contractor)
Blue Cross Blue Shield of NC
2017.09 - 2018.02
- Answer incoming phone calls from agents and identify the type of assistance needed
- Assisted agents with inquiries regarding health benefits, eligibility, billing and payments, authorizations for procedures, explanation of benefits, and claims
- Educated agents on their health benefits options, supporting informed decision-making during open enrollment periods
- Focus on resolving issues on the first call, navigating through complex computer systems to identify the status of the issue and provide appropriate response to caller
- (Facets, WebNow, Nuxeo, Agent Portal, Power, Service 1st, 834 Spreadsheet)
- Participated actively in regular team meetings aimed at driving continuous improvement initiatives across various aspects of agent services operations
- Forwarded claims to appropriate departments for review and adjustment when claim denial errors are discovered
- Deliver information and answer questions in a positive manner to facilitate strong relationships with provider agents
- Complete the documentation necessary to track issues and facilitate the reporting of overall trends
- Reviewed pharmacy claims in RX claims application, and verified prescriptions and pricing in Prime
Customer Service Representative (Contractor)
Blue Cross Blue Shield of NC
2016.10 - 2017.04
- Provide benefit information to customers
- Forwarded claims to appropriate departments for review and adjustment when claim denial errors are discovered
- Assist with making plan options available via bcbsnc.com
- Focus on resolving issues on the first call, navigating through complex computer systems to identify the status of the issue and provide appropriate response to caller
- (Facets, WebNow, Power, Service 1st, 834 enrollment spreadsheets, Magic)
- Identify customers' needs, clarify information, research every issue, and provide solutions and/or alternatives
- Assist with questions regarding claims and authorizations on file
- Provide accurate, valid, and complete information by using the right methods/tools
- Verify payments received via PPU
- Route task to appropriate department
Provider Service Representative
Xerox- BCBS of Ohio
2015.05 - 2016.09
- Answered inbound calls from hospitals, medical practices, and substance abuse/mental health facilities to answer medical policy insurance inquiries
- Provided up to date benefits stating copay, deductible, coinsurance, and out of pocket values for specific medical procedures
- Researched cpt codes for various medical procedures giving accurate benefits and supporting medical policies that may influence medical claim approval
- Reviewed medical policy bulletins if applicable for providers with claim denials
- Forwarded claims to appropriate departments for review and adjustment when claim denial errors are discovered
- Explained provider offsets/refunds to providers when payments are recouped for claims paid in error
Receptionist/Office Assistant
Vance-Granville Community College
2014.08 - 2015.05
- Assist students with class schedules
- Process requests for transcripts
- Alphabetize and file student documents
- Assist dean with special projects
- Answer incoming at front desk regarding transcripts, application, and enrollment questions
Customer Service Representative
Xerox-Sprint Cellular
2013.02 - 2013.10
- Assisted with processing bill payments, and billing information
- Troubleshoot mobile devices, setup appointments for store repairs
- Create tickets for customers regarding service issues
- Answer inbound calls regarding account information
- Assist with placement of orders, refunds, or exchanges
- Recommend potential products or services to management by collecting customer information and analyzing customer needs
Sales Associate
Belk
2010.11 - 2012.04
- Ensure high levels of customers satisfaction through excellent sales service
- Process POS purchases
- Maintain in-stock and presentable condition assigned area
- Process payments for Belk customers
- Handle all cash transactions for register
- Count money in cash drawers at the beginning of shifts to ensure that amounts are correct and that there is adequate change
- Receive payments by cash, cheques, and credit cards
Associate Sales Representative
Olan Mills-Studio
2008.06 - 2008.11
- Meet daily sales requirement
- Scheduled appointments for customer photo sessions
- Use telephones to reach out to customers and verify account information
- Greet customers warmly as they enter and exit the studio
- Process order for photo packages
- Receive payments by cash, cheques, and credit cards
- Presented regular updates on sales progress at team meetings, sharing best practices with colleagues for improved productivity.
- Mentored junior team members on best practices in sales and relationship management, contributing to overall team growth and development.
Customer Service Representative
BB&T Call Center
2004.12 - 2007.05
- Provide client information regarding their BB&T accounts
- Provided information to clients about their auto and/or mortgage loan
- Assisted with online banking login and password resets
- Submitted research information to appropriate department
- Recommend potential products or services to customers collecting customer information and analyzing customer needs
- Provide dealer payoff for auto loans for dealerships
Education
Business Administration -
Fayetteville Technical Community College
Fayetteville, NC12.2025
Skills
Customer Service
Attention to detail
Insurance Claims Review
Policy understanding
Medicaid knowledge
Teamwork and Collaboration
Insurance Coverage Verification
Denied claims identification
Data Entry
Proficient in Facets
Understanding of medical terms
Multitasking
Reliability
Organizational Skills
Pharmaceutical knowledge
Timeline
Claims Representative
Blue Cross Blue Shield North Carolina
2024.04 - Current
Group Services Representative
Blue Cross Blue Shield North Carolina
2019.09 - 2024.04
Patient Service Representative
Affordable Dentures & Implants
2019.05 - 2019.08
Agent Services Representative (Contractor)
Blue Cross Blue Shield of NC
2018.12 - 2019.02
Agent Services Representative (Contractor)
Blue Cross Blue Shield of NC
2017.09 - 2018.02
Customer Service Representative (Contractor)
Blue Cross Blue Shield of NC
2016.10 - 2017.04
Provider Service Representative
Xerox- BCBS of Ohio
2015.05 - 2016.09
Receptionist/Office Assistant
Vance-Granville Community College
2014.08 - 2015.05
Customer Service Representative
Xerox-Sprint Cellular
2013.02 - 2013.10
Sales Associate
Belk
2010.11 - 2012.04
Associate Sales Representative
Olan Mills-Studio
2008.06 - 2008.11
Customer Service Representative
BB&T Call Center
2004.12 - 2007.05
Business Administration -
Fayetteville Technical Community College
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