Summary
Overview
Work History
Education
Skills
Timeline
Generic

Tracey M. Smith

Jacksonville,Florida

Summary

A results-oriented professional with over thirty years’ experience in claims and committed to continuous improvement and education. Proven track record as a motivator, coach, and flexible team player. High Energy Supervisor successful in building and motivating dynamic teams. Cultivates a company culture in which staff feel comfortable voicing questions and concerns as well as contributing new ideas that drive company growth. Organized and diligent with excellent written, oral, and interpersonal communication. Effective communicator with genuine people skills. CORE QUALIFICATIONS Operations Management Staff Development Inventory Control Performance Metrics Cross-functional Team Management Performance Evaluations Computer Savvy Supervision and Training

Overview

29
29
years of professional experience

Work History

Supervisor Claims JCA

CVS Healthcare Aetna
05.2019 - Current
  • Provides direction, instruction, and guidance to examiners for the purpose of achieving TAT and Quality goals
  • Able to identify examiner’s strengths and weaknesses
  • Develop and implement strategies used to reach team goals
  • Provide training via communicating clear instructions
  • Manage the flow of day-to-day operations
  • Distribute reports to the appropriate individuals
  • Serve as a mentor and motivator
  • Able to make sound decisions and work with all supervisors and staff at all levels of responsibility
  • As a superb communicator able to think, communicate and present information effectively to people of all social backgrounds
  • Identify all issues in team and provide continuous support to all members according to operating standards
  • Builds a cohesive team through collaboration, inclusion, and diverse thinking
  • Responsible for ensuring satisfaction through prompt, accurate and careful claim handling
  • Develop, train, evaluate and coach team to provide cost effective claim review/processing and claim service while ensuring compliance and quality standards are met
  • Oversee effective working of production personnel and prepare effective production schedules and ensure compliance to all company policies
  • Act as liaison between team and other areas communicating workflows, results, ideas, and solutions
  • Utilize available incentive programs to reward, recognize, and celebrate team and individual success
  • Responsible for fostering discussions surrounding problem identification and escalation for resolution
  • Vast knowledge of Institutional and Professional claims processing and pricing
  • Knowledge of HMO, PPO, Medicaid, Medicare, JCA and Traditional claims processing
  • ASQ CQIA: American Society for Quality, Certified Quality Improvement Associate
  • Vast knowledge of AMA, ASA, and CMS guidelines

Team Lead

AMERIHEATH CARITAS
06.2014 - 01.2019
  • Provides direction, instruction, and guidance to examiners for the purpose of achieving TTP and Quality goals
  • Able to identify examiner’s strengths and weaknesses
  • Develop and implement strategies used to reach team goals
  • Provide training via communicating clear instructions
  • Manage the flow of day-to-day operations
  • Distribute reports to the appropriate individuals
  • Serve as a mentor and motivator
  • Able to make sound decisions and work with supervisors and staff at all levels of responsibility
  • As a superb communicator able to think, communicate and present information effectively to people of all social backgrounds
  • Identify all issues in team and provider continuous support to all members according to operating standards
  • Oversee effective working of production personnel and prepare effective production schedules and ensure compliance to all company policies
  • Coordinate with process teams ensuring compliance to all protocols and maintain quality
  • Vast knowledge of Institutional and Professional claims processing and pricing
  • Knowledge of HMO, PPO, Medicaid, Medicare and Traditional claims processing
  • ASQ CQIA: American Society for Quality, Certified Quality Improvement Associate
  • Coordinated Team Luncheons
  • Vast knowledge of AMA, ASA, and CMS guidelines
  • Provided up training to transitional associates
  • Provided additional department specific training to new employees

Referral Specialist /Trainer

ST. VINCENT’S MEDICAL CENTER
06.2013 - 06.2014
  • Efficiently perform new patient pre-registration and scheduling processes accurately while providing excellent customer service
  • Provide quality services to internal and external customers
  • Adhere to the department and scheduling guidelines
  • Answer incoming calls in a prompt and courteous manner
  • Verify insurance coverage and benefits
  • Triage telephone calls and handle appropriately
  • Identify appointments with insurance concerns: incomplete information, out of network policies, and authorization request
  • Ensure that urgent diagnosis and appointments are handled with high priority
  • Process eReferrals, faxed referrals, and live calls for appointments
  • Educate patients on the preparation for the appointment or requirements needed to ensure productive visit
  • Provide directions to specialist clinics/offices
  • Interact with coworkers and clinic personnel in a professional manner
  • Request medical records when required
  • Provide a 72 hours response time for all referrals received
  • Demonstrate reliability in daily work practices with a clear understanding of St
  • Vincent’s Referral Center policies and procedures
  • Accurately notate patients account to communicate pertinent information to the specialist, registration, and billing departments
  • Stay abreast of appointment scheduling changes, insurance requirements, and respond accordingly
  • Follow-up on all referrals via phone, voice mail, and fax to ensure patient care
  • Schedule appointments according to established guidelines
  • Confirm appointments with the patients, referring physician, and specialist office
  • Trained incoming Referral Specialist

Financial/ Insurance Manager

ECONOMY DENTURES
05.2011 - 01.2013
  • Responsible for the daily maintenance of insurance information, patient coverage verification, procedure restrictions and coverage limitations imposed by various insurance entities
  • Maintained acceptable account aging balances on the PPO and Medicaid patient levels
  • Managed the Billing Department for multiple clinics
  • Verify insurance coverage and benefits for new patients by necessary means
  • Re-verify insurance coverage for existing patients
  • Identify appointments with insurance concerns: incomplete information, out of network policies, no dental coverage and take appropriate action
  • Enter insurance information in patient files and complete updates when necessary
  • Create insurance alerts annotating benefits, frequencies, non-covered procedure, age specific limitations, x-rays requirements and narratives
  • Scan all insurance documents into the document center under subscribers family file
  • Submit pre-treatment estimates per each insurance company’s guidelines as requested by the patient care coordinator; scan documents into document center, create alert to track request
  • Respond to all correspondence from insurance companies taking appropriate action to resolve an issues
  • Initiate and maintain PPO programs for insurance network participations; ensure completeness of paper work
  • Check completeness and accuracy of treatment posted on each patient ledger; correct entries as needed per insurance held by patient; check clinical notes to verify treatment adding procedure not captured on ledger such as nitrous and/or x-rays taken
  • Alert appropriate staff members concerning patients with incomplete clinical notes, charge outs, incorrect provider and treatment plans still requiring posting
  • Process refund request and organizational write-offs
  • Electronically send all claims; take appropriate action for rejected claims
  • Submit paper claims as needed for secondary insurance companies and primary when required
  • Process all insurance payments received and negotiate payment plans for patients
  • Create alerts for patient balances and forward collection notices
  • Manage all EOB discrepancies; make corrections and resubmit claims as required
  • Monitor Aging report and update fee schedules

Quality Auditor, Associate

BLUE CROSS BLUE SHIELD OF FLORIDA, THE PRUDENTIAL INSURANCE COMPANY
11.1999 - 08.2007
  • Perform post examination of claims, telephone calls, and written inquiries
  • Conduct analysis to determine root cause of problem(s) identified and suggest improvement opportunities
  • Facilitate and participate in department twc’s designed to deliver recommendations for improvements
  • Proficient in Diamond, DDERS, QUEST, MHS, IMS, RBMS, CICS, NASCO, CONVERGENCE, CMCA, GMIS, and MIF
  • Vast knowledge of Institutional and Professional claims processing an pricing
  • Vast knowledge of AMA, ASA, and CMS guidelines
  • Strong background in recalculations and customer service
  • Proficient in various computer applications
  • Subject Matter Expert for Virtual Office
  • Facilitated TWC’s
  • Coordinated Team Luncheons
  • Pulse Survey Champion Work Group
  • Diversity Work Group
  • Shared Service Organizational Affinity Work Group
  • Knowledge of HMO, PPO, and Traditional claims processing
  • Yellow-Belt Certified
  • ASQ CQIA: American Society for Quality, Certified Quality Improvement

Claims Examiner

06.1996 - 10.1999
  • Responsible for accurately examining, interpreting, and entering claims data into the claims processing system in a timely manner
  • Received, organized, and made effective use of informa- tion regarding benefits, contract coverage and policy decisions
  • Maintained excellent quality and production
  • Provided peer training
  • Back-up to Provider Service Reps
  • Back-up to Re-works Reps
  • Coordinated Desk Buddy Program

Claims Examiner

BLUE CROSS BLUE SHIELD OF FLORIDA
10.1994 - 06.1996
  • Responsible for accurately examining, interpreting, and entering claims data into the claims processing system in a timely manner; performed necessary research and effectively made decisions to properly adjudicate claims within benefits and claims processing guidelines
  • Maintained excellent quality and production

Education

Florida State College
Jacksonville, Florida
12.2024

AA Degree -

Florida State College
Jacksonville, Florida
12.2017

William M. Raines Senior High School
Jacksonville, Florida
06.1986

Skills

  • Leadership and Change Management
  • Customer Service Management
  • Research and Analysis
  • Data Analysis and Modeling
  • Administration and Operations
  • Report Preparation and Analysis
  • Teamwork and Collaboration
  • MS Office
  • Training and Development
  • Excellent Communication
  • Written Communication
  • Teambuilding
  • Interpersonal Communication
  • Analytical and Critical Thinking
  • Meeting Coordination and Support
  • Coordinate Schedules
  • Flexible and Adaptable

Timeline

Supervisor Claims JCA

CVS Healthcare Aetna
05.2019 - Current

Team Lead

AMERIHEATH CARITAS
06.2014 - 01.2019

Referral Specialist /Trainer

ST. VINCENT’S MEDICAL CENTER
06.2013 - 06.2014

Financial/ Insurance Manager

ECONOMY DENTURES
05.2011 - 01.2013

Quality Auditor, Associate

BLUE CROSS BLUE SHIELD OF FLORIDA, THE PRUDENTIAL INSURANCE COMPANY
11.1999 - 08.2007

Claims Examiner

06.1996 - 10.1999

Claims Examiner

BLUE CROSS BLUE SHIELD OF FLORIDA
10.1994 - 06.1996

Florida State College

AA Degree -

Florida State College

William M. Raines Senior High School

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Tracey M. Smith