Porschia Sanford
FL
Summary
To obtain a challenging position within a reputable company that would enable to utilize previous work experience while also providing an opportunity for advancement, growth and development.
Overview
11
11
years of professional experience
Work History
Appeals and Grievance Analyst
Florida Blue (Blue Cross and Blue Shield of Florida)
2017.10 - Current
- Manages and adjudicates member and provider disputes arising under the Grievance System including member grievances, appeals and requests for hearing and provider claim and disputes
- Investigates findings of encounter denials and explains to management underlying reasons for identified data quality issues
- Communicates with providers to resolve problems with appeal requests that are not submitted according to Plan's policy
- Review customer complaints, listen to customer phone calls, and review other documentation as available
- Completes the appeals process within an established timeframe documented in current Plan's policy
- Collects, analyzes and reviews historical authorization information to incorporate into departmental appeal documentation
- Accountable for compliance with record retention plan according to Plan's policy
- Coordinates the presentation of appeals to the Appeals Committee and participates as a member
- Communicates decisions (in writing) made by the Appeals Committee to providers within Plan timeframe
- Updates or creates authorizations for services that have been appealed and communicates this information to the Medical Claims department
- Summarize findings in a write up as well as provide an initial opinion on if the nature of the customer complaint qualifies the customer for a refund
- Prepares written case summaries and forwards to the Medical Director for review taking appropriate action as indicated by Medical Director's determination to ensure timely resolution
- Expedited resolution times by proactively communicating with members, providers, and other stakeholders throughout the grievance process.
- Processed and finalized appeals and grievances within agreed-upon turnaround time.
- Remained knowledgeable regarding company policies and procedures and current developments within operational departments.
Service Advocate 3
Florida Blue (Blue Cross and Blue Shield of Florida)
2013.10 - 2017.10
- Provides assistance to the company members by responding to benefits, eligibility and claim related inquires via the telephone and in writing
- Extensive knowledge of Blue Options, Blue Care, BlueChoice, Blue Select, and GoBlue Products
- Serves as the member liaison to ensure inquiries are resolved on the initial contact
- Educates and answers member's questions on the access and use of member self-service tools
- Supports and continuous improvement by actively seeking and identifying improvements to processes and services from the members' perspective
- Provide support to groups and Business Administrators on complex claims and customer service inquiries
- Operate outbound phones to business partners, providers and Business Administrators to research and resolve customer's inquiries
- Extensive knowledge of internal data bases such as RBMS, Seibel, Diamond, CMCA, Quest, PIP, Member Website, CTIOS, ICB and more
- Knowledgeable on various compliance guidelines including HIPAA and ERISA
- Daily inventory management or personal and team pending and work collaboratively with team members to ensure that timeliness goals are met
- Knowledge of Providers services and claims
- Services calls and correspondence from members and providers and resolves provider and health plan claim inquiries
- Develop and maintains relationships with internal and external business partners such as Sales, HPS, Prime Therapeutics, New Directions, NIA, and Membership and Billing
- Note taker during Team Meetings and TWCs
- Ulysses Service Mentor certified
- Attended and facilitated call calibration sessions and process improvement meetings to update DTPs, SOPs, and departmental procedures
- Processed claim forms, adjudicates for provision of deductibles, co-pays, or co-insurance maximums and provider settlements
- Researches claim overpayments and requests funds
- Provided timely customer service to members, providers, billing departments and other insurance companies on the subject of claims.
Education
High School Diploma -
Duncan U Fletcher Senior High
01.2006
Skills
- Problem-solving skills
- Ability to work in a team
- Strong work ethic
- Strong reading comprehension
- Analytical and quantitative skills
- Communication skills
- Leadership qualities.
- Intermediate Excel and Microsoft Word
Timeline
Appeals and Grievance Analyst
Florida Blue (Blue Cross and Blue Shield of Florida)
2017.10 - Current
Service Advocate 3
Florida Blue (Blue Cross and Blue Shield of Florida)
2013.10 - 2017.10
High School Diploma -
Duncan U Fletcher Senior High
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