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STEPHANIE DRESSLER
Insurance Configuration and Benefits Analysis
McAllen,TX
Work Preference
Summary
Healthcare configuration and operations professional with 10+ years of experience across Blue Cross Blue Shield organizations, healthcare benefits administration, claims adjudication, FACETS configuration, Plan-to-Plan operations, benefit implementation, accumulator analysis, claims reprocessing, and healthcare systems support. Extensive experience translating complex business requirements into system configuration, troubleshooting adjudication issues, validating benefit accuracy, supporting regulatory compliance, and partnering with business and technical stakeholders. Recognized for strong analytical skills, process improvement initiatives, root-cause analysis, and successful implementation of medical and pharmacy benefit changes.
Experienced with managing and implementing system configurations to ensure optimal performance. Utilizes strong analytical skills and attention to detail to identify and rectify configuration issues. Knowledge of industry-standard tools and best practices for configuration management.
Overview
12
12
years of professional experience
Work History
Senior Liability Claims Representative
Bristol West Insurance Group / Farmers Insurance Group
McAllen, TX
04.2022 - Current
- Coordinate the lifecycle of complex claims, facilitating their progression from assignment through to successful resolution.
- Analyze coverage liability damages and claim documentation to uphold compliance with regulatory standards.
- Review claims for fraud indicators and round table with special investigators
- Achieve effective collaboration with attorneys and repair shops, enhancing service quality. Strengthened relationships with insurance carriers and agents, resulting in improved operational efficiency.
- Negotiate settlements for soft tissue bodily injury claims to ensure fair compensation.
- Review and authorize payment of subrogation claims to ensure compliance with company policies.
- Transcribe and organize recorded statements to facilitate review and analysis.
- Conductthorough reviews of police reports to support investigative processes and enhance case management.
- Facilitate mentorship for new employees, enhancing onboarding workflow and technical process understanding.
- Oversaw management of competing priorities to ensure adherence to quality and service standards.
Operations Applications Analyst / Plan-to-Plan Specialist
Blue Cross and Blue Shield of Kansas City
Kansas City, MO
07.2019 - 04.2022
- Configured complex medical and pharmacy benefits within FACETS including copays, coinsurance, deductibles, accumulators, out-of-pocket maximums, and tiered pharmacy cost-share structures.
- Supported implementation and maintenance of large employer group benefits while ensuring accurate claims adjudication and compliance with benefit design requirements.
- Generated Summary of Benefits and Coverage (SBC) documentation supporting member communication and regulatory compliance.
- Investigated claims payment discrepancies and performed root-cause analysis to identify configuration defects and coding issues.
- Coordinated claims reprocessing initiatives to correct adjudication outcomes and improve member and provider experience.
- Validated benefit setup, accumulator functionality, and configuration accuracy through testing and quality review activities.
- Collaborated with sales, auditors, employer groups, operations teams, customer service, and IT to implement benefit changes and resolve production issues.
- Produced reporting and analysis on impacted claims populations to support corrective actions and operational decision-making.
- Developed standard operating procedures and participated in enterprise cleanup initiatives to improve configuration consistency and operational efficiency.
- Chosen as one of four specialists to oversee intricate plan-to-plan operations and benefit transition initiatives.
Operations Manager
Blue Sprig Pediatrics
Harlingen, TX
01.2019 - 05.2019
- Enhanced clinic operations by refining insurance verification and prior authorization follow-up processes. Strengthened compliance monitoring efforts to ensure adherence to regulations. Improved operational workflows, resulting in increased clinic efficiency.
- Coordinated and led informative tours, providing families with essential insights and resources.
- Conducted safety training programs aimed at reducing workplace incidents and promoting a culture of safety.
- Executed new hire paperwork processing to streamline employee integration into the organization.
- Coordinated and executed exit paperwork and surveys, contributing to the enhancement of employee retention strategies.
- Analyzed incidents of inappropriate behavior and executed corrective actions, ranging from formal write-ups to termination, to uphold workplace standards.
- Coordinated schedules for registered behavior technicians to ensure effective client support.
- Orchestrated social events for clinic staff and families to foster community engagement.
- Managed facility maintenance issues resolution to uphold safety and functionality standards.
Human Resources Assistant
Plymouth Village / HumanGood
Redlands, CA
10.2017 - 01.2019
- Managed employee benefits administration and ensured compliance with onboarding documentation.
- Developed and executed training modules to familiarize new hires with company policies and culture.
- Monitored and ensured adherence to compliance requirements for nursing and physician licensing.
- Managed the screening process for prospective employees to identify qualified candidates. Coordinated interview schedules and organized fingerprinting appointments for selected applicants.
- Delivered comprehensive training sessions on computer skills to enhance employee proficiency and supported technology-related inquiries for time-off requests.
- Coordinated logistics and outreach for benefits fairs, ensuring effective communication of program details to employees.
- Designed and facilitated social events for employees to foster a positive workplace culture.
- Administered structured exit interviews, focusing on understanding employee motivations for departure and enhancing retention strategies.
- Addressed and responded to contacts regarding wage garnishments and child support liens to ensure compliance and support affected individuals.
Customer Service Representative / Coordination of Benefits Specialist
BLUE CROSS AND BLUE SHIELD OF KANSAS CITY
01.2014 - 01.2017
- Acted as subject matter expert to facilitate coordination of benefits claims research and payment analysis.
- Identified and resolved eligibility concerns and payment discrepancies affecting claim adjudication efficiency.
- Reviewed mock claims to provide customers with clarity on service eligibility and financial implications.
- Interpreted customer contracts to resolve inquiries regarding benefits.
- Analyzed and reprocessed claims to correct payment errors and enhance operational efficiency.
- Engaged with providers to troubleshoot and rectify issues related to billing and claims submissions.
Education
Master of Science - Clinical Psychology
Regent University
Virginia Beach, VA12.2024
Bachelor of Science - Business Administration
Old Dominion University
Norfolk05.2006
No Degree - Pre-Pharmacy
West Virginia University
Morgantown, WV05.2005
Skills
- FACETS
- Benefit Configuration
- Medical Benefits
- Pharmacy Benefits
- Claims Adjudication
- Claims Reprocessing
- Accumulator Management
- Deductibles
- Out-of-Pocket Maximums
- SBC Generation
- BlueCard
- Medicare
- Medicaid
- Commercial Products
- UAT Testing
- Configuration Validation
- Root Cause Analysis
- Production Support
- Business Analysis
- Benefit Coding
- Plan Implementation
- SOP Development
- Microsoft Excel
ADDITIONAL QUALIFICATIONS
- 10+ years of healthcare and insurance industry experience
- Direct FACETS benefit configuration experience
- Strong understanding of healthcare claims adjudication and benefit administration
- Experience supporting Commercial, Medicare, Medicaid, and BlueCard operations
- Proven ability to bridge business, operations, and technical teams
Timeline
Senior Liability Claims Representative
Bristol West Insurance Group / Farmers Insurance Group
04.2022 - Current
Operations Applications Analyst / Plan-to-Plan Specialist
Blue Cross and Blue Shield of Kansas City
07.2019 - 04.2022
Operations Manager
Blue Sprig Pediatrics
01.2019 - 05.2019
Human Resources Assistant
Plymouth Village / HumanGood
10.2017 - 01.2019
Customer Service Representative / Coordination of Benefits Specialist
BLUE CROSS AND BLUE SHIELD OF KANSAS CITY
01.2014 - 01.2017
Master of Science - Clinical Psychology
Regent University
Bachelor of Science - Business Administration
Old Dominion University
No Degree - Pre-Pharmacy
West Virginia University