Rosalind McCray
Bentonville,AR
Summary
Highly experienced Analyst who achieves exceptional results through innovation, critical thinking, initiative, and resourcefulness. With over 18 years of experience in the health insurance industry obtained at a fortune500 company (13 of those in a analyst position). Solid knowledge of comprehensive claims payment procedures, systems, and testing environments. Thrives in ambiguous circumstances with minimal direction and resources; strong ability to gather, compile, and test data using seasoned analytical skills. Reputation as a self-directed professional with superior problem solving, communication, and interpersonal skills. Successful in managing time, prioritizing tasks, and organizing projects to improve the quality of internal and external practices throughout organization. Over 18 years of internal experience in AMISYS and CSW. Excellent analytical skills with a high degree of accuracy. Strong written and oral communication skills. Knowledgeable of HCPC, CPT4, ICD9 and ICD10 coding processes.
Overview
19
19
years of professional experience
Work History
Quality Assurance Analyst
Arkansas Blue Cross Blue Shield
Little Rock, AR
08.2010 - 07.2022
- Monitored resolution of bugs, tested fixes and helped developers tackle ongoing problems by providing QA perspective.
- Performed quality control audits for 30 examiners, reviewed, and monitored departmental functions for claims, membership, customer service, workflow processes support systems, procedures, and documentation.
- Mentored and coached team members on QA topics and strategies.
- Wrote and maintained detailed internal documentation on developed systems.
- Created and gained project approval on project test plans.
- Supported company in maintaining work environment focused on quality, communication, collaboration, integration, and teamwork.
- Fixed identified issues to increase productivity and boost workflows.
Provided one-on-one feedback recommending preventative and corrective action to maintain and adhere to quality standards. - Authored and updated Standard Operating Procedures according to department procedures.
Leveraged capability to efficiently work with minimal supervision in virtual environment. - Prepared quality data electronically, critical to management reports and presentations
summarizing quality trends and systems inaccuracies.
- Recorded assessments electronically into file review database, compiled monthly and
quarterly reports.
- Prepared Quality system review to help ensure that operational departments are prepared for
external audits.
- Assisted and facilitated claims portion of training focusing on processes for new and seasoned employees.
- Documented testing procedures for developers and future testing use.
- Wrote and maintained detailed internal documentation on developed systems
Claims Specialist/Adjustment Specialist
Arkansas Blue Cross Blue Shield
Little Rock, AR
02.2005 - 08.2010
- Processed high dollar claims in AMISYS as third-party administrator for Walmart group with 98% overall accuracy rating.
- Researched, investigated, and determined correct order of benefits for payment to be made by applicable plans and made necessary corrections.
- Reviewed all previously processed claims to ensure consistency in payments to maximize recovery of overpayments following corporate and departmental guidelines to ensure financial stability.
- Responsible for accurate and timely processing of complex claims and/or adjustments to ensure all contractual obligations are met with highest level of member/provider satisfaction.
- Reviewed audits and responded to all error reporting within specified deadlines following
departmental and corporate guidelines to ensure accuracy of claims processing and customer satisfaction.
Customer Service Specialist
Arkansas Blue Cross Blue Shield
Little Rock, AR
10.2003 - 02.2005
- Acted as liaison between all customer service support functions, group administrators, members/policyholders, and providers.
- Investigated and resolved member inquiries through correspondence and computer research.
- Advised customers regarding policy and benefit information for multiple health plans.
- Coordinated internal activities necessary to research and resolve inquiries and provide accounts
with service solutions. - Met and exceeded daily, weekly, and monthly performance goals.
- Assisted with training of new staff, as well as mentor trainees.
- Addressed customer complaints and mitigated dissatisfaction by employing timely and on-point solutions.
- Provided primary customer support to internal and external customers.
- Achieved 99% high satisfaction rating through proactive one-call resolutions of customer issues.
- Participated in team meetings and training sessions to stay informed about product updates and changes
Skills
- AMISYS
- Manual Testing
- Issue Resolution
- Analytical and Critical Thinking
- Report Delivery
- Process Implementation
- Inpatient and Outpatient Claims
- Testing Plans
- Pricing and Configuration
Accomplishments
- Tested and implemented a tracking system for analyst inventory control and reporting.
- Implemented standard QA database.
- Instrumental in developing processes for executive company physical and international claims.
- Served as liaison between claims department and WalMart benefit area.
- Analysis of data sets for special projects.
- Accurate interpretation of the claims detail and facts which lead to accurate and appropriate claims payment.
- Record and compile QR results. Report individual and department QR results on a weekly and monthly basis to claims department management
- Review QR results to identify process problems and training needs. Report process problems along with possible solutions to claims department management. Through review of claims and pending report, identify system problems and refer them to IT management
Skills
AMISYS, Assurance Analyst, Audit, Claims, Claims Processing, CSW, Inventory, Kronos, Medicaid, Operations, Processing Claims, Quality Assurance, Training, Accounting, Adjustments, Blue Cross, Blue Cross Blue Shield, Coding, Customer Service, Data Entry, Front End, Healthcare, Hospital Claims, HIPPA, Icd9, Interpersonal, Inventory Control, Microsoft Teams, Medical Claims, Medical Claims Processing, Medical Terminology, Marketplace, Medicare, Microsoft office, Pricing and Configuration, Problem Solving, Processing Experience, Project Management, Self-directed, Software Release, Solutions, Testing, Workday
Timeline
Quality Assurance Analyst - Arkansas Blue Cross Blue Shield
08.2010 - 07.2022
Claims Specialist/Adjustment Specialist - Arkansas Blue Cross Blue Shield
02.2005 - 08.2010
Customer Service Specialist - Arkansas Blue Cross Blue Shield
10.2003 - 02.2005