Nicole McGee
Portsmouth,VA
Summary
Proven in enhancing service optimization and fostering strategic business relationships, I excelled by driving quality assurance and provider support. My expertise in claims reviewing and conflict management led to significant workflow improvements, showcasing the ability to merge hard skills with soft skills for impactful results. Provides seamless customer service to providers in fast-paced call center environments. Excellent communication, relationship-building and problem-solving abilities. Diligent, attentive and quality-driven.
Overview
10
10
years of professional experience
Work History
Provider Relations Representative
Medix Staffing-Sentara Health Plans
2023.10 - Current
- Managed provider relations mailbox by triaging inquiries, facilitating resolution of incoming requests and forwarding requests to appropriate parties.
- Fostered strong, positive relationships with key providers by coordinating, facilitating and leading partnership meetings and identifying on-site enrollment opportunities.
- · Analyzing insurance information: Reviewing claims submissions, verifying information, and analyzing insurance policies
- · Handling claims issues: Addressing claim issues, deciding whether a claim should be processed or denied, and processing claim payments
Performance Quality Analyst
Elevance Formerly Anthem
2019.07 - 2023.10
- Evaluates the quality and accuracy of transactions and/or communications with providers, groups, and/or policyholders.
- Identifies, documents, and reports any transaction errors or communications issues in a timely manner to ensure prompt resolution.
- Monitored resolution of bugs, tested fixes, and helped developers tackle ongoing problems by providing QA perspective.
- Gathered data on integration issues and vulnerabilities, reported findings and recommended improvements.
- Associates at this level conduct routine audits, generally related to a single function on a single systems platform for a single line of business.
Utilization Management Correspondence Rep
Anthem Inc
2019.07 - 2022.06
- Responded to customer questions via telephone and written correspondence regarding insurance benefits, provider contracts, eligibility, and claims.
- Research authorizations and case notes to ensure accuracy of Behavioral Health criteria and denials.
- Developed and maintained positive customer relations and coordinated with team members to properly handle requests and questions.
- Collaborate with other departments to produce letters for services denied in respective units
- Completes denial letters for services denied by Medical Director.
Patient Access Representative
CHKD - The King's Daughters
2020.12 - 2022.03
- Identified insurance payment sources and listed payers in proper sequence to establish chain of payment.
- Obtained patient's insurance information and determined eligibility for benefits for specific services rendered.
- Performed patient scheduling and registration functions to serve as initial contact point for medical office visits.
- Collected and entered patient demographic and insurance data into computer database to establish patient's medical record.
- Utilized knowledge of electronic medical record systems and medical terminology to perform diverse data entry tasks.
- Received patient deductibles and co-pay amounts and discussed options to satisfy remainder of patient financial obligations.
Utilization Management Representative Sr.
Anthem Inc.
2016.05 - 2019.07
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Submitted cases for criteria failures and helped facilitate resolutions and approvals.
- Facilitated workgroup meetings with medical personnel to find effective solutions to issues.
- Supervised and maintained all utilization review documentation.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
Senior Customer Care Representative
Anthem
2014.07 - 2016.05
- Helped large volume of customers every day with positive attitude and focus on customer satisfaction.
- Logged call information and solutions provided into internal database.
- Assisted call-in customers with questions and orders.
- Responded to customer needs through competent customer service and prompt problem-solving.
- Trained new employees on best practices and customer care procedures to eliminate inefficiencies.
- Communicated with clients regarding account services, statements, and balances.
- Addressed customer complaints and mitigated dissatisfaction by employing timely and on-point solutions.
Education
Associate of Applied Science - Medical Billing And Coding
Everest Institute-Hialeah, FL
11.2009
GED -
Chesapeake Adult Education Center
Chesapeake, VA02.2008
Skills
- Service Optimization
- Provider relationship management
- Strategic Business Relationships
- Conflict Management
- Quality Assurance
- Claims reviewing
- Provider orientations
- Provider support
- Project Management
- Workflow Analysis
- Health plan operations
Timeline
Provider Relations Representative
Medix Staffing-Sentara Health Plans
2023.10 - Current
Patient Access Representative
CHKD - The King's Daughters
2020.12 - 2022.03
Performance Quality Analyst
Elevance Formerly Anthem
2019.07 - 2023.10
Utilization Management Correspondence Rep
Anthem Inc
2019.07 - 2022.06
Utilization Management Representative Sr.
Anthem Inc.
2016.05 - 2019.07
Senior Customer Care Representative
Anthem
2014.07 - 2016.05
Associate of Applied Science - Medical Billing And Coding
Everest Institute-Hialeah, FL
GED -
Chesapeake Adult Education Center
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