LESLEY CLEVELAND-MORRIS

• Maintained knowledge of benefits claim processing, claims principles, medical terminology and procedures and HIPAA regulations.
• Paid or denied medical claims based upon established claims processing criteria.
• Read over insurance policies to ascertain levels of coverage and determine whether claims would receive approvals or denials.
• Interpret provider contracts to ensure payment/denial accuracy.
• Medicaid and Medicare Fee Schedules in order to pay correct rate.

• Supports learning environment
• Works independently, demonstrates initiative and innovative thinking, clear and concise communication skills.
• With healthcare voice experience, member services
• Good analytical and mathematical ability,
• Floor walking during live transaction processing for real time problem solving skills (REMOTELY)
• Daily Client Interaction
• Serve as mentor to new agents
• Rate agents weekly on performance
• Led corporate-wide initiatives to help guide enterprise and business level goals.
• Provided customer and network administration services such as passwords, electronic mail accounts and troubleshooting.
• Collaborated with senior management and business line management to identify and prioritize new concepts for development and launch.
• Researched claims and incident information to deliver solutions and resolve problems.
• Evaluated all evidence with ultimate goal of creating positive outcomes for client's claims.
• Reviewed questionable claims by conducting agent and claimant interviews to correct omissions and errors.
• Processed/adjudicate claims, updated providers contracts, NPI, TIN.
• Utilized Trizetto NetworX Pricer
• Submitted timely and accurate assessments of team performance to leadership with identification of areas of opportunity and outlined steps required to improve outcomes.
• Researched issues related to claims processing to identify origins and implement corrective solutions.
• Provided high level of professionalism when speaking with customers or responding to emails to promote company's dedication to service.
• Prioritized daily tasks to satisfy workload demands and department's turnaround goals.
• Reviewed insurance claims and member eligibility to determine overpayment trends and noncompliance issues.
• Demonstrated leadership skills in managing projects from concept to completion
• Strengthened communication skills through regular interactions with others
• Assisted with day-to-day operations, working efficiently and productively with all team members

• Responsible for reviewing, analyzing and processing medicals claims. In addition, responsible for validating claims to ensure accurate and timely processing.
• Gain and maintain understanding of plan designs and effectively apply that knowledge.
• Managed large volume of medical claims on daily basis.
• Used administrative guidelines as resource or to answer questions when processing medical claims.
• Maintained knowledge of benefits claim processing, claims principles, medical terminology and procedures and HIPAA regulations.
• Maintained knowledge of benefits claim processing, claims principles, medical terminology, and procedures and HIPAA regulations
• Used administrative guidelines as resource or to answer questions when processing medical claims
• Managed large volume of medical claims on daily basis
• Paid or denied medical claims based upon established claims processing criteria
• Paid or denied medical claims based upon established claims processing criteria.
• Responded to correspondence from insurance companies.

Assist USAA members with (FNOL) is the initial report made to the insurance provider following a loss, theft or damage of an insured asset.

• Verify member eligibility and policy coverage
• Investigate members loss
• Explain to member process of reporting and obtain details of loss
• Assign claims/loss to Analyst
• Worked well in team setting, providing support and guidance
• Used critical thinking to break down problems, evaluate solutions and make decisions

• Build rules situation with the Peradigm System, in coordination within State and Federal Guidelines
• Monitors and tests accuracy of price rules
• Builds and tests contracts and pricing templates for non-par and new business teams
• Resolves provider load issues within appropriate time
• Loads professional contracts into Diamond system through appropriate research and provider data load activities
• Xcelys, FACETS, AMISYS, DST Pricer. QNXT
• Configured medical contracts in claims adjudication/pricing system
• Prepared test cases and conducted User Acceptance Testing of Fee Schedules and payable procedure code testing and implementation of required health plan benefits and payment structure changes
• Interpreted and configured provider contracts, tested payable procedure codes and fee schedules in Facets 5.10
• Resolved System Edits and Claim Workflow issues
• Support client configuration changes and new configuration requirements, including configuration analysis design, build and test
• Excellent communication skills, both verbal and written
• Passionate about learning and committed to continual improvement
• Provided professional services and support in dynamic work environment
• Maintained knowledge of benefits claim processing, claims principles, medical terminology and procedures and HIPAA regulations. Paid or denied medical claims based upon established claims processing criteria. Read over insurance policies to ascertain levels of coverage and determine whether claims would receive approvals or denials. Interpret provider contracts to ensure payment/denial accuracy. Medicaid and Medicare Fee Schedules in order to pay correct rate.

• Correctly coded and billed medical claims for various hospital and nursing facilities
• Determined prior authorizations for medication and outpatient procedures
• Resourcefully used various coding books, procedure manuals and on-line encoders
• Posted and adjusted payments from insurance companies
• Researched CPT and ICD-9 coding discrepancies for compliance and reimbursement accuracy
• Confidently and adeptly handled claim denials and/or appeals
• Actively maintained current working knowledge of CPT and ICD-9 coding principles, government regulation, protocols and third party requirements regarding billing
• Assist with preparation with business requirements and configured claims focusing on tables, payments, Service ID, Service Definition, Service Rules and conducted detailed system analyst configuration
• NetworX configuration
• Excel-VLOOKUP and Pivot Tables
• Precisely completed appropriate claims paperwork, documentation and system entry
• Utilizing Facets processing
• Worked well in a team setting, providing support and guidance
• Used strong analytical and problem-solving skills to develop effective solutions for challenging situations.
• Build rules situation with the Peradigm System, in coordination within State and Federal Guidelines Monitors and tests accuracy of price rules Builds and tests contracts and pricing templates for non-par and new business teams Resolves provider load issues within appropriate time Loads professional contracts into Diamond system through appropriate research and provider data load activities Xcelys, FACETS, AMISYS, DST Pricer. QNXT Configured medical contracts in claims adjudication/pricing system Prepared test cases and conducted User Acceptance Testing of Fee Schedules and payable procedure code testing and implementation of required health plan benefits and payment structure changes Interpreted and configured provider contracts, tested payable procedure codes and fee schedules in Facets 5.10 Resolved System Edits and Claim Workflow issues Support client configuration changes and new configuration requirements, including configuration analysis design, build and test Excellent communication skills, both verbal and written Passionate about learning and committed to continual improvement Provided professional services and support in a dynamic work environment

Responsible for identifying, tracking and reconciling overpayment made to providers and ensuring that recovery is made and reported.

• Processed hospital and skilled nursing facility claims via Medicaid following State guidelines per assigned States
• Processed physician, Outpatient claims per Medicare following federal guidelines
• Perform authorized duties in processing of of overpayment allocated to all assigned markets consistent with applicable company and departmental policies
• Respond to calls, letters and emails from agents, vendors and/or Provider disputes
• Maintain working knowledge of all company products and services pertaining to business
• Work with Health Plan regarding overpayment's/Provider disputes
• Communicate with providers regarding overpayment disputes
• Adhere to company and department policies and procedures as well as HIPAA regulations
• NetworX pricer/Configuration using FACETS for complex pricing.
• Amisys
• Perform other duties as requested or assigned - systems (Compass & Contact Logs) FACETS for all markets
• SPECIAL TEAM TESTER - Provided detailed analysis using Microsoft Access queries, troubleshooting and correcting issues utilizing Microsoft Access, SQL and Excel. Reporting and updating Facets data to ensure proper configuration process
• Process Encounter information based on Capitation Methodology
• Maintained client confidentiality and adhered to HIPAA guidelines

Assist in incoming calls explaining claim denials and provided payment information as well as benefit coverage information for members.

• Worked effectively in fast-paced environments.
• Skilled at working independently and collaboratively in team environment.
• Proven ability to learn quickly and adapt to new situations.
• Completed paperwork, recognizing discrepancies and promptly addressing for resolution.
• Assist in incoming calls explaining claim denials and provided payment information as well as benefit coverage information for members. Worked effectively in fast-paced environments Skilled at working independently and collaboratively in team environment Proven ability to learn quickly and adapt to new situations Completed paperwork, recognizing discrepancies and promptly addressing for resolution.
• Self-motivated, with strong sense of personal responsibility.
• Developed strong organizational and communication skills through coursework and volunteer activities.
• Managed time efficiently in order to complete all tasks within deadlines.
• Proven ability to learn quickly and adapt to new situations.

• Promoted to team lead of customer service for displaying outstanding enthusiasm and remaining calm in extremely trying situations
• Resolved customer service issues using company processes and policies and provided updates to customers
• Took cash and credit card payments via phone, in person, and through email
• Utilized active listening skills to understand customer needs and provide tailored solutions
• Escalated issues to proper supervisors when standard processes were not effective
• Checked status of orders and back-ordered products to coordinate efficient shipments
• Assisted customers with product selection, troubleshooting and problem resolution
• Reached out to customers after completed sales to suggest additional service or product purchases
• Cross-trained and provided backup support for organizational leadership
• Exhibited high energy and professionalism when dealing with clients and staff
• Promoted superior experience by addressing customer concerns, demonstrating empathy, and resolving problems swiftly
• Responded to customer requests, offering excellent support and tailored recommendations to address needs

• Duties included handling inbound/outbound telephone calls in call center environment/dispatched orders for refilling beverage and equipment repairs in FLORIDA market.
• Provided primary customer support to internal and external customers.
• Resolved concerns with products or services to help with retention and drive sales.
• Achieved high satisfaction rating through proactive one-call resolutions of customer issues.
• Maintained customer satisfaction with forward-thinking strategies focused on addressing customer needs and resolving concerns.
• Maintained and managed customer files and databases.
• Answered customer telephone calls promptly to avoid on-hold wait times.
• Responded to customer requests for products, services, and company information.
• Processed customer service orders promptly to increase customer satisfaction.
• Handled customer inquiries and suggestions courteously and professionally.

• Handling inbound calls regarding General Motors vehicle warranty and scheduling for repairs and preventative maintenance. Handling escalated customer/dealership issues processed customer courtesy discount and goodwill adjustments for vehicle repairs.
• Developed and maintained courteous and effective working relationships.
• Worked effectively in fast-paced environments.
• Used strong analytical and problem-solving skills to develop effective solutions for challenging situations.
• Acted as team leader in group projects, delegating tasks and providing feedback.
• Demonstrated leadership skills in managing projects from concept to completion.
• Excellent communication skills, both verbal and written.
• Worked well in team setting, providing support and guidance.
• Participated in team projects, demonstrating ability to work collaboratively and effectively.