Lisa Hawes
Newport,Ohio
Summary
In my professional career I worked for the same insurance company for fifteen years. I started out in customer service taking fifty-eighty inbound calls per day. Went over patient benefits, claims and made calls to provider's when necessary to get correct information on office visits. I became a lead customer service representative over thirteen customer service advocates. I helped them with questions; such as how a claim processed, how to read a benefit and acted a the floor supervisor when necessary. During my time I was also promoted to Supervisor, Appeals and Compliance for Affordable Care. Then I went to Medicare Advantage non-clinical appeals.
Overview
17
17
years of professional experience
Work History
Patient Financial Representative - Patient Accounting
Marietta Health Systems
08.2023 - 03.2025
- Follows ethical billing practices.
- Exhibits exceptional customer service skills, utilizing AIDET.
- Maintains compliance with patient accounting policies and procedures.
- Completes special projects as assigned.
- Maintains a comprehensive awareness of all insurance company updates including Federal and State guidelines.
- Assumes all other duties and responsibilities as necessary.
- Reviews, edits and submits claims.
- Performs timely denial follow up and resubmission of claims, including correct reimbursement review until the account is resolved by either receiving payment or rejection of claim.
- Answersed thirty to forty inquiries from patients, guarantors, patient’s families, attorneys and third-party payers about billing procedures and resolve problems.
- Worked forty KeyBridge Inquiries.
- Work forty Alpha split emails.
- Work forty MediTech assigned tasks.
- Help other team members when they have questions.
Medicare Advantage Appeals – Non-Clinical
Highmark BlueCross BlueShield
10.2018 - 07.2023
- The job conducts and documents thorough investigations of all complaint and grievance case types, communicating resolutions to members in accordance with Center for Medicare and Medicaid Services (CMS) requirements.
- Working up to thirty appeals at a time to ensure compliance for each one.
- Requires broad knowledge of plan products, processes, and enrollment rules.
- Responsible for all aspects of nonclinical appeals, up to and including decision making, considering potential impacts to regulatory compliance as well as CMS star ratings.
- Provides support to clinical appeals, facilitating member verbal and written notification and correct authorization of services.
- CTM complaints, investigation and response to executive and legislative inquiries also performed by the Appeal Analyst.
- Complete and document thorough investigation of all grievances and appeals.
- Perform research and evaluate output requirements and formats.
- Request and review all related relevant documentation and assemble case file.
- Ensure accurate documentation of cases in the appeals management system, maintaining compliance with CMS reporting and data validation requirements.
- Effective and compliant effectuation of appeals.
- Communicate business operational requirements to internal groups responsible for compliant handling.
- Review and determine outcome of appeal/grievance, either independently or in conjunction with clinical appeal staff.
- Compose and complete oral and written responses to all parties.
- Communicate effectively with colleagues, successfully articulate issues, problems, and solutions.
- Assist in functional walk throughs.
- May require additional support from more experienced team members.
- Recommend process efficiencies, strategies for improvement and/or solutions to align with business strategies.
- Assist with small to intermediate cross-functional projects and change initiatives involved in the design and delivery of process solutions, implementing strategies and control measures, influencing organizational changes related to business processes.
- Participate in process improvement meetings and/or discussions, recommending process efficiencies and/or strategies for improvement.
- Ensure quality assurance of appeal/grievance work, assist in development of desktop procedures and/or training materials.
- Other duties as assigned.
Supervisor Appeals and Compliance Administration
Highmark BlueCross BlueShield
09.2014 - 10.2018
- Perform management responsibilities including but limited to involved in hiring and termination decisions, coaching and development, rewards, and recognition, performance management and staff productivity.
- Plan, organize, staff, direct, and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.
- Decide workflow for the day and assign work to the team.
- Monitor and manage daily inventories to ensure adequate staffing and resources are available to ensure Performance guarantees and established goals are met and supported.
- Monitor 10 calls per day for 10 different staff members for quality assurance and compliance.
- Research quality issues and respond to error assessments.
- Maintain department logs and documentation, analyze for trends to identify and initiate future pro-active measures.
- Produce and analyze reports through various systems and databases, focusing on productivity, quality, and compliance.
- Ensure compliance with all regulatory entities (i.e., DOH, CMS, NCQA, etc.)
- Create, implement, monitor and report on the policies and procedures to ensure all required business/compliance standards are met.
- Represent the department in compliance audits as it relates to the supervisor’s functions.
- Function as subject matter expert for benefit plan and claim processing.
- Research and investigate any privacy or compliance concerns (CMS, HIPAA, internal policy, etc.).
- Complete root cause analysis and address remediation process with impacted employees.
- Participating in process improvement initiatives as appropriate, which may involve working across teams and with different levels of management.
- Troubleshoot escalated cases, which may involve speaking with providers via phone.
- At times, build cases in Utilization Review system during high volume times.
- Other duties as assigned or requested.
Customer Service Representative and Lead Customer Service Representative
Highmark BlueCross BlueShield
09.2008 - 09.2014
- Responsible for taking fifty (50) or more inbound calls per day from customers.
- Applies in-depth product knowledge obtained through ongoing cycles of working with routine and non-routine subject matter.
- Regardless of recurring and routine customer inquiries, comments, and concerns, approaches each and every interaction with superior listening skills.
- Multi-tasks with a high level of efficiency yet treats every customer as the most important during the interaction so as not to leave the customer with a hurried impression.
- Ability to ask effective probing and/or open and closed ended questions that will help in issue resolution in a conversational manner with customers, using verbal clues and system tools to develop tailored recommendations for the customer.
- Ability to master initial training competencies while demonstrating the ability to learn additional competencies through additional training.
- Ability to de-escalate challenging customer inquiries, comments, and concerns while delivering necessary information consistent with Company policies and processes.
- Communicate effectively with colleagues, successfully articulate issues, problems, and solutions.
- Assist in functional walk throughs.
- May require additional support from more experienced team members.
- Recommend process efficiencies, strategies for improvement and/or solutions to align with business strategies.
- Assist with small to intermediate cross-functional projects and change initiatives involved in the design and delivery of process solutions, implementing strategies and control measures, influencing organizational changes related to business processes.
- Participate in process improvement meetings and/or discussions, recommending process efficiencies and/or strategies for improvement.
- Other duties as assigned.
Education
High School Diploma -
Frontier High School
New Matamoras, OH05.1991
Skills
- Excellent customer service skills
- Analytical and problem-solving skills with attention to detail
- Decision Making
- Excellent ability to communicate both verbally and in writing
- Ability to prioritize and manage multiple tasks
- Proficient computer skills and knowledge of Microsoft Office
- Educated in Medicare, Medicaid and Commercial insurance
- Ability to learn new technologies and possess the technical aptitude required to understand flow of data through systems as well as system interaction
Timeline
Patient Financial Representative - Patient Accounting
Marietta Health Systems
08.2023 - 03.2025
Medicare Advantage Appeals – Non-Clinical
Highmark BlueCross BlueShield
10.2018 - 07.2023
Supervisor Appeals and Compliance Administration
Highmark BlueCross BlueShield
09.2014 - 10.2018
Customer Service Representative and Lead Customer Service Representative
Highmark BlueCross BlueShield
09.2008 - 09.2014
High School Diploma -
Frontier High School
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