Nancy Dominique

Contributes to the Bill Review division in a support capacity. Investigates and resolves issues with bills received from our clients and providers.

Communicates with clients, vendors, providers, stakeholders, and other involved parties for any additionally required information to support processing issue bills.

Establishes new providers and assists with provider setup. Provides recommendations regarding process improvements. Completes output in specific work area to appropriate time and quality targets.

Works under own initiative, prioritizes own work, and meets agreed timescales. Work is subject to frequent review by more experienced Analysts.

Streamlined operations for increased efficiency by implementing new processes and procedures.

Facilitated training programs for team members, enhancing their skills and knowledge base for better job performance.

Follow established claim policies and practices to resolve claims and issues and make determinations.

Track record of working productively with limited supervision

Identify and obtain missing information and input into system.

Respond to inquiries, handle outbound calls needed, handle customer escalations.

Manages an assigned caseload of minimally complex claims.

Develops and maintains strong working relationships with internal and external customers.

Effectively and independently manages an assigned caseload of moderately complex claims which consists of pending, ongoing/active and appeal reviews

Provides timely, balanced and accurate claims reviews, documentation and recommended decisions in a time sensitive and fast-paced environment and in accordance with state and department of insurance regulations

Participated in continuous training programs to stay current on industry trends, best practices, and regulatory changes impacting disability claims management.

Established credibility with claimants by demonstrating empathy, integrity, and professionalism throughout the claims process.

Mentored new Disability Claims Examiners on best practices, helping them quickly acclimate to the role and become effective contributors to the team''s success.

Maintained up-to-date knowledge of industry trends to better serve customers'' needs effectively.

Resolved complex customer issues, demonstrating deep knowledge of company products and services.

Enhanced customer satisfaction by promptly addressing inquiries and providing accurate information.

Processes claims that pend for various hold reasons to assist in the final determination on claim disposition.

Processes adjustments related to projects or provider disputes providing timely follow-up provider call backs.

Acts as Claims Department subject matter expert on departmental and corporate projects. Supports business definition and testing efforts, attends project meetings, maintains project plans and provides internal and external status reports.

Works with management and associates to document current business and workflow processes and collaborates in identifying, defining and documenting process improvement options and alternatives.

Researches complex claims issues with banking deposit and works with other departments to resolve. Serves as primary liaison to all external departments, markets, and banking on claims related content.

Analyzes and trends claims issues, performs true root cause analysis and determines next steps for resolution and process improvement.

Communicates changes in processes, project status and issue resolutions through email, memos, group presentations, and/or individual one-off meetings

Improved claim processing efficiency by streamlining workflows and implementing time-saving strategies.

Identified fraudulent claims through diligent investigation and collaboration with law enforcement agencies when necessary.

Developed strong working relationships with external partners such as adjusters, legal counsel, and medical professionals to facilitate efficient claim resolution processes.

Achieved performance targets consistently through attention to detail, effective time management, and strong decision-making abilities.

Processes claims that pend for various hold reasons to assist in the final determination on claim disposition.

Processes adjustments related to projects or provider disputes providing timely follow-up provider call backs. • Acts as Claims Department subject matter expert on departmental and corporate projects. Supports business definition and testing efforts, attends project meetings, maintains project plans and provides internal and external status reports.

Works with management and associates to document current business and workflow processes and collaborates in identifying, defining and documenting process improvement options and alternatives.

Researches complex claims issues and works with other departments to resolve. Serves as primary liaison to all external departments, markets, and providers on claims related content.

Analyzes and trends claims issues, performs true root cause analysis and determines next steps for resolution and process improvement.

Researches issues, compiles feedback and drafts corresponding business requirements documents and business decision documents as needed.

Reduced claim processing time for faster customer service and improved satisfaction rates.

Handled escalated customer concerns regarding claim denials or delays with empathy and professionalism.

Managed high volume of claims, prioritizing tasks to meet deadlines without sacrificing quality.

Monitored changes in legislation that could potentially impact the way claims are processed or paid out by insurance companies.

Processes Institutional, Professional claims that pend for various hold reasons to assist in the final determination on claim disposition

Provide expertise or general claims support by reviewing, researching, investigating, negotiating, processing referrals and adjusting claims, DME for Medicaid community and state programs

Analyze and identify trends and provide reports as necessary

Consistently meet established productivity, schedule adherence and quality standards

Facets system process contact with hospitals and medical system for claim

Evaluate medical claims for accuracy and complete

Analyses claim data to identify trends and root causes of claim errors

Verify diagnosis codes and procedure codes according to established protocols

Assess medical claims to ensure adherence to company policies and regulations.

.Review critical errors from EDI submissions, research and correct data in system.

Review various system settings in new system

. Analyzed claims for data corrections.

Responsible for in depth understanding of pharmacy’s services and is able to articulate to staff to ensure pharmacy processes are followed and stated goals are met with increased safety and efficiency Understands thoroughly the AdventHealth employee prescription plan and supports the prescription benefit account team by offering support and education when communicating with staff , members and physician office(s) on any questions regarding formulary coverages, eligibility, prior authorization or general plan guidelines Helps manage and track the use of benefit related service activities, including but not limited to package replacements, prescription resend and operational overrides. Serves as a point of escalation for calls requiring a higher degree of expertise or discretion to resolve customer issues and ensures timely resolution. Communicates with department Manager, any areas of concern for future service. Plays an active role in the Customer Service Triage process, ensuring those that are speaking with customers have all the resources and education needed to provide accurate and helpful information to all callers. Monitors the main Rx Plus Pharmacy contact center wallboard, ensuring all member calls are answered in a timely manner, requesting backup as necessary; takes phone calls as appropriate. Works to achieve an abandonment rate, average speed to answer, and other performance indicators within stated goals. Monitors the main pharmacy email inbox, working with organizational teams to provide prompt, courteous and helpful information to members. Ensures members’ needs are met and tasks are completed as promised. Fills in for Customer Service Manager when absent, covering specific duties as assigned Works within registered pharmacy technician mandated scope of practice guidelines.

Managed budgets effectively, ensuring optimal allocation of resources and adherence to financial guidelines.

Developed staff skills through targeted training programs, resulting in improved performance and career growth opportunities.

Identified operational inefficiencies and implemented corrective measures to increase effectiveness.

Collaborated with other departments to achieve organizational goals, fostering teamwork across various functions.