ROMONA WILLIAMS
Elgin,SC
Summary
Certified Professional Coder leveraging over 15 years of healthcare insurance experience in medical claims processing, coding, and claims adjudication. Proven ability to analyze complex claims and benefit issues, ensuring compliance with regulatory standards while enhancing operational efficiency through process improvements and provider education.
Overview
1
1
Certification
14
14
years of professional experience
Work History
Dedicated Service Consultant
BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA
Columbia, SC
12.2025 - Current
- Educate groups and members on healthcare benefits, benefit selection, claims processes, and self-service resources to empower informed decision-making.
- Maintain current knowledge of contracts, claims payment policies, benefit structures, and procedures to resolve complex healthcare service inquiries.
- Research and resolve claim and benefit issues while ensuring decisions align with applicable group contracts and organizational policies.
- Utilize coding resources, reimbursement methodologies, and claim adjudication guidelines to analyze healthcare services and determine appropriate member benefit application.
- Track, analyze, and trend service inquiries to identify recurring issues and inform process improvement initiatives.
- Develop reports to monitor account inquiries and identify trends, supporting targeted benefit education and service enhancements.
- Interpret coded healthcare services and apply benefit provisions for employer groups, brokers, partner plans, and healthcare providers.
- Create educational materials and conduct presentations, demonstrations, and individual meetings.
Provider Relations Consultant
BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA
Columbia, SC
10.2023 - 12.2025
- Reviewed and researched medical claims using CPT, ICD-10-CM, and HCPCS coding systems to investigate claim outcomes, payment issues, and benefit inquiries.
- Evaluated coded medical services during complex claims investigations and provider reimbursement inquiries.
- Applied National Correct Coding Initiative (NCCI) edits and established coding standards during the review of claim outcomes and reimbursement determinations.
- Researched reimbursement methodologies, fee schedules, provider contracts, and medical policy guidelines to support accurate claim resolution.
- Investigated complex and time-sensitive provider issues involving medical and administrative policies, reimbursement, contracts, and claims.
- Provided education to healthcare providers regarding billing requirements, electronic claim submission, reimbursement, enrollment, contractual requirements, and Medicaid benefits and eligibility.
- Cultivated professional relationships with hospitals, physicians, behavioral health providers, and healthcare organizations to enhance collaboration and support.
- Facilitated provider training, workshops, conferences, and annual education sessions to ensure compliance with billing practices and reimbursement procedures.
- Developed training materials and trained new employees supporting Healthy Blue Medical and Behavioral Health operations.
- Acted as subject matter expert for complex provider and claims-related issues, providing guidance and resolution strategies.
Senior Quality Assurance Analyst
BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA
Columbia, SC
05.2022 - 10.2023
- Conducted quality evaluations to identify processing deficiencies and recurring errors, leading to targeted corrective actions.
- Identified process gaps and developed recommendations enhancing productivity, accuracy, workflow, and quality outcomes.
- Performed high-dollar and floor-limit claim audits to evaluate accuracy, consistency, regulatory compliance, internal procedures, and quality standards.
- Delivered quality assurance training to new and existing employees through in-person and virtual sessions, improving overall team competency.
- Analyzed operational results and developed weekly and monthly performance reports for leadership.
- Supported adherence to regulatory requirements, internal procedures, operational standards, and quality expectations.
Account Advocate
BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA
Columbia, SC
09.2019 - 05.2022
- Resolved complex provider and member claims inquiries, complaints, appeals, and grievances to enhance customer satisfaction.
- Evaluated claim processing issues and identified appropriate resolution based on benefit provisions, contractual requirements, and processing guidelines.
- Educated members and providers regarding billing, claims payment, processing procedures, and applicable policies.
- Conducted comprehensive research to ensure accurate processing of appeals, complaints, and grievances in compliance with regulatory and organizational requirements.
- Researched claims processing guidelines, provider contracts, fee schedules, and system configurations to determine root causes of payment errors.
- Developed operational reports to monitor quality, productivity, and efficiency.
- Implemented procedures to streamline workflow and ensure consistent claims processing.
Benefit Files Analyst
BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA
Columbia, SC
02.2018 - 09.2019
- Analyzed and evaluated new and existing healthcare benefit plans for accurate configuration and application within internal systems.
- Identified and addressed process and system issues impacting accurate healthcare benefit administration.
- Conducted quality control reviews to ensure accuracy, completeness, and timeliness of benefit-related assignments.
- Tested internal systems and configurations to identify processing errors and functionality issues.
- Investigated discrepancies, communicating findings and recommendations to facilitate corrective action.
Claims Customer Service Coordinator
BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA
Columbia, SC
11.2016 - 02.2018
- Functioned as work leader within the State Health Plan Claims Department, supporting accurate and timely claims processing.
- Reviewed and adjudicated high-dollar institutional claims in accordance with established processing guidelines and management approval requirements.
- Applied knowledge of professional and institutional claims processing, regulatory guidelines, and quality requirements.
- Served as a liaison between internal departments to investigate claim, system, procedural, and quality issues.
- Evaluated employee performance and identified training needs to enhance productivity and accuracy in claims processing.
- Trained and mentored claims associates on processing and customer service procedures to ensure high-quality service delivery.
- Collaborated with management to streamline claims processes and enhance operational support structures.
Claims Customer Service Advocate
BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA
Columbia, SC
01.2016 - 11.2016
- Researched and adjudicated second-pass claims for specialized infertility, prescription drug, and pharmacy reversals, ensuring accurate claim resolution.
- Performed first-pass processing and data entry for CMS-1500 and UB-04 claim forms.
- Reviewed reports and account information to identify discrepancies, updating member claim history to maintain accuracy and compliance.
- Developed desk procedures for specialized claims processing and reporting functions, improving clarity and consistency for team use.
- Conducted staff training related to specialized claims reports and processing procedures.
Claims Customer Service Advocate
BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA
Columbia, SC
11.2014 - 01.2016
- Researched and processed healthcare claims according to established processing guidelines and contractual benefit provisions.
- Reviewed claims information and contacted members to obtain necessary documentation for accurate claim adjudication.
- Applied knowledge of ICD-9 and CPT coding in support of claims processing and resolution.
- Utilized third-party administrator claims knowledge to enhance accuracy in healthcare claim processing.
- Completed daily claims-related reports accurately and on time to support operational efficiency.
- Assisted with training and onboarding of new employees.
Claims Customer Service Advocate
BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA
Columbia, SC
11.2012 - 10.2013
- Reviewed claims status, system edits, deferrals, medical records, and appeals to ensure accurate and timely claims resolution.
- Resolved system edits and processing deferrals to support accurate claims adjudication and payment.
- Researched and resolved medical claims inquiries and processing issues for dedicated plan accounts.
- Evaluated medical records and appeals information to confirm claim eligibility for timely adjudication.
- Monitored claims processing trends to pinpoint recurring issues and recommend actionable improvements.
- Researched account information and claims history using internal databases and systems.
Education
High School Diploma -
Spring Valley High School
Columbia, SC05-2023
Skills
- Certified Professional Coder (CPC)
- Medical Coding
- CPT Coding
- ICD-10-CM Coding
- HCPCS Coding
- Claims processing
- Medical Claims Adjudication
- Claims analysis
- Claims Auditing
- NCCI Edits
- Reimbursement Methodologies
- Fee Schedule Research
- Medical Billing
- Healthcare Benefits
- Provider Contracts
- Regulatory Compliance
- Operational Quality Control
- Discrepancy resolution
- Appeals management
- Claims Investigations
- Provider Relations
- Documentation Review
- Data Analysis & Reporting
- Process Improvement
- Training programs
- Issue resolution
- Member Support Services
- Data entry
- Microsoft Office Suite
- Analytical and critical thinking
- Attention to detail
- Effective communication
- Task prioritization
Personal Information
Title: CERTIFIED PROFESSIONAL CODER (CPC) | MEDICAL CODING | CLAIMS & REVENUE CYCLE
Certification
Certified Professional Coder (CPC), AAPC | July 2026
Timeline
Dedicated Service Consultant
BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA
12.2025 - Current
Provider Relations Consultant
BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA
10.2023 - 12.2025
Senior Quality Assurance Analyst
BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA
05.2022 - 10.2023
Account Advocate
BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA
09.2019 - 05.2022
Benefit Files Analyst
BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA
02.2018 - 09.2019
Claims Customer Service Coordinator
BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA
11.2016 - 02.2018
Claims Customer Service Advocate
BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA
01.2016 - 11.2016
Claims Customer Service Advocate
BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA
11.2014 - 01.2016
Claims Customer Service Advocate
BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA
11.2012 - 10.2013
High School Diploma -
Spring Valley High School