Melissa Jade Quesenberry
Leeds,AL
Summary
Efficient professional in insurance claims and policy processing, known for high productivity and the ability to complete tasks with precision. Specialized in analyzing claim details, navigating policy databases, and managing customer communications. Excel in problem-solving, adaptability, and teamwork, leveraging these soft skills to navigate complex situations and achieve positive outcomes.
Overview
3
3
years of professional experience
Work History
Claims Processor I
Medical University of South Carolina
Charleston, SC
05.2022 - 01.2025
- Conducted extensive investigations into follow-up invoices (denial and no response) across various physician specialties, ensuring timely and accurate payment resolutions
- Researched policy guidelines, carrier benefits, payment trends, coding classifications, medical records, and agency regulations to ensure compliance and optimize claim processing
- Disputed insurance denials and addressed member policy discrepancies to secure appropriate reimbursement for rendered medical services, often on the basis of medical necessity
- Collaborated with medical professionals and legal teams to review claim disputes and facilitate proactive resolutions
- Implemented workflow optimizations that reduced claim processing time and improved turnaround rates
- Trained and mentored new hires on claims procedures, system navigation, and compliance best practices
- Analyzed payment trends to identify and proactively address emerging revenue loss patterns, implementing measures to prevent recurring issues
- Processed an average of 60 claims per day while maintaining a 95% accuracy rate and exceeding departmental efficiency benchmarks
Claims Customer Service Advocate II
BlueCross BlueShield of South Carolina
Columbia, SC
08.2021 - 04.2022
- Managed 50 - 100 impound inquiries daily, providing expert assistance to State Health Plan members and healthcare providers while consistently exceeding departmental performance standards
- Served as the primary point of contact for escalated member calls, successfully de-escalating high-stress situations and resolving complex inquiries to ensure customer satisfaction and internal policy compliance
- Leveraged extensive knowledge of group benefits and policy details to educate members, facilitate informed decision-making, and enhance communal comprehension of healthcare insurance mechanisms
- Delivered accurate and empathetic customer support for claims processing, preauthorization requests, and appeals, employing a solution-driven approach to resolve complex payout issues
- Maintained leading Quantified Communications (QC) scores, reflecting a commitment to quality and customer satisfaction at every point of external contact
- Mastered advanced software systems, including the Resource Access Control Facility (RACF), to conduct thorough research and efficiently resolve member inquiries
Education
Bachelor of Arts - Psychology
University of Arizona Global Campus
Chandler, AZ09.2025
Skills
Technical & Research Skills
Clinical Research Support
Participant Engagement
Regulatory Knowledge
Data Analysis, Mining, & Management
Statistical Analysis
Workflow Development
Diagnostic Formulation
Project Management
Software Mastery & Technical Proficiency
Marketing
Interpersonal & Professional Skills
- Customer Service
- Mentorship
- Crisis Intervention Techniques
- Conflict Resolution & Negotiation
- Interpersonal Awareness & Active Listening
- Adaptability & Cultural Competency
- Professional Integrity & Confidentiality/Ethics
- Altruism & Commercial Awareness
Cognitive & Organizational Skills
- Analytical Thinking & Problem-Solving
- Informational Literacy
- Efficient Task & Time Management
- Collaboration
Accolades
Honors Preparatory School Graduate, South Carolina Virtual Charter School - Independent Learning, Ranked in the top 6% Class of 2020 (4.3 GPA)
Timeline
Claims Processor I
Medical University of South Carolina
05.2022 - 01.2025
Claims Customer Service Advocate II
BlueCross BlueShield of South Carolina
08.2021 - 04.2022
Bachelor of Arts - Psychology
University of Arizona Global Campus