Pamela Long
Summary
Dynamic professional with extensive experience at Blue Cross Blue Shield of Michigan, excelling in critical thinking and problem-solving. Proven track record in resolving complex grievances and Appeals that enhancing customer satisfaction. Adept at multitasking and managing high volumes of inquiries while utilizing Microsoft tools to deliver accurate solutions efficiently.
Overview
24
24
years of professional experience
Work History
Grievance and Appeals Coordinator
Blue Cross Blue Shield of Michigan
02.2022 - 03.2025
- Analyze, research, resolve and respond to confidential/sensitive complaints, appeals, grievances and organization determinations from members, member's representatives, providers, media outlets, senior leadership and regulatory agencies with established regulatory and accreditation guidelines
- Make appeals complaints and grievance decisions and communicate decisions to the claimant within regulatory and accreditation guidelines for timeliness, adhering to the strictest of timeframes for urgent and non-urgent requests, as imposed by the various federal and state laws.
- Analyze, research, resolve and respond to high level inquiries, referrals, complaints, and appeals received from various regulatory agencies and other sources.
- Develop/prepare reports regarding the types/volumes/causes of inquiries received.
Medicare Advantage Customer Service Representative
Blue Cross Blue Shield of Michigan
02.2020 - 02.2022
- Provides primary customer support to internal and external customers, providers, and agents in fast paced environment.
- Analyze, evaluate, resolve, respond and adjudicate to resolution customer provider inquires received via telephone and written correspondence involving variety of claim/benefit issue under a plethora of products.
- Handled escalated calls efficiently, finding satisfactory resolutions for both customers and the company alike.
- Assisted customer care representative in navigating Medicare documents to ensure accurate information provided to members and providers.
- Assist other representatives and handle unusual or complex inquires, irate calls
- Maintained detailed records of customer interactions, ensuring proper follow-up and resolution of issues.
Medicare Customer Service Representative
Blue Cross Blue Shield of Michigan
06.2017 - 02.2019
- Effectively and efficiently assist members and providers with verbal or written correspondence involving claims and benefit issues under various groups or individual contracts.
- Conduct internal and external research to determine accurate adjudication of claim processing or refer claims for escalation or clinical review.
- Conduct internal and external research to determine accurate adjudication of claim processing or refer claims for escalation or clinical review.
- Technically skilled in navigating multiple software programs to provide accurate and complete customer service to the members and providers.
- Provided exceptional support to Medicare beneficiaries, guiding them through coverage options and plan details.
- Managed a high volume of inbound calls, adeptly navigating multiple systems while maintaining focus on customer needs.
Customer Service/Sales Representative
AT&sT
01.2001 - 07.2017
- Boosted sales revenue by identifying customer needs and recommending appropriate products or services.
- Built rapport with customers through empathetic listening and understanding their unique needs or preferences.
- Increased customer satisfaction by addressing and resolving complex issues effectively.
- Managed high call volume, ensuring timely response and effective resolution to all customer concerns.
Education
High School Diploma -
Northwestern High School
Detroit, MISkills
- Critical thinking
- Microsoft
- Teams
- (Word, Excel, Powerpoint)
- Problem-solving
- Time management
- Attention to detail
- Multitasking
Timeline
Grievance and Appeals Coordinator
Blue Cross Blue Shield of Michigan
02.2022 - 03.2025
Medicare Advantage Customer Service Representative
Blue Cross Blue Shield of Michigan
02.2020 - 02.2022
Medicare Customer Service Representative
Blue Cross Blue Shield of Michigan
06.2017 - 02.2019
Customer Service/Sales Representative
AT&sT
01.2001 - 07.2017
High School Diploma -
Northwestern High School
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