TRACI EDWARDS WILLIAMS

Responsible for managing to resolution complaint and appeal scenarios for all products, which may contain multiple issues and, may require coordination of responses from multiple business units. Ensure timely, customer focused response to complaints/appeals. Medicare and Medicaid experience following up with Insurance companies to inquire about payment of claims.

• Research incoming electronic complaints/appeals to identify if appropriate for unit based upon published business responsibilities. Identify correct resource and reroute inappropriate work items that do not meet complaint/appeal criteria.
  
• Assemble data used in making the denial determination, assemble, summarize and send resolution.
  
• Research Medicaid benefits pertinent to the member to determine accuracy/appropriateness of benefit/administrative denial.
  
• Research claim processing logic to verify accuracy of claim payment, member eligibility data, billing/payment status, prior to initiation of appeal process.
  
• Identify and research all components within member or provider/practitioner complaints/appeals for all products and services
• Triage incomplete components of complaints/appeals to appropriate subject matter expert within another business unit(s) for resolution response content to be included in final resolution response.
  
• Responsible for coordination of all components of complaints/appeals including final communication to member/provider for final resolution and closure

• I Provide Medicare Part A and/or B telephone inquiries, by researching CMS policies and procedures for Medicare request from the Medicare provider community which includes details on CPT coding, verifying information regarding Medicare coverage guidelines and policies which cover a wide range of topics to include provider enrollment, Medicare appeals, debt recovery, claim payment information, telephone reopening requests, and general coverage for multiple provider specialties
• Access multiple systems to research customer problems and record inquiry types
• Research CMS and company websites to provide knowledge and education to customer on additional resources which can be used in the future
• Access the IVR and Internet Portal systems as needed to help educate customers on self-service options that are available to them
• Review local medical coverage and national medical coverage policies in order to troubleshoot reasons for claim denials and reductions
• Review other system to address and determine resolution to other customer issues to include pending appeals, aged claims, and Medicare Secondary Payer
• Engage in dialogue with all customers using a customer-friendly tone even when challenged with overly aggressive customers
• Respond to each customer's need and request and ensure each customer's encounter is positive and productive
• I Use good verbal communication during each customer encounter and never use jargon and slang during customer calls
• Embrace diverse backgrounds and understand the needs of those customers who may not have as extensive knowledge of Medicare rules and regulations
• Tailor responses to ensure customers receive the maximum benefit when calling Medicare

• Coordinate the delivery of re-determination decisions from and to DME Medicare Administrative Contractors (MACs).
• Build a reconsideration case file from evidence submitted,received and analyze each case to ensure it meets the requirements for a valid reconsideration request mandated by Centers for Medicare and Medicaid Services (CMS).
• Respond to reconsideration requests from appellants.
• Route or respond to telephonic and/or written inquiries from appellants about reconsiderations or its process from appellant or their legally-designated representatives.Updated departmental standard operating procedures and database to accurately reflect the current practices.Promptly responded to general inquiries from members, staff, and clients via mail, e-mail and fax.
• B/OCR Data entry and Medicare Part A Teleworker.

• I provided excellence Customer Service by accurately examining,interpreting and entering Medicare claims,resolving edits utilizing the OCR claims processing system,performing necessary research and effectively making decisions to properly adjudicate claims utilizing the processing manual(Stellant),identify and communicate problems relevant to the claims processing system and the processing manual and/or guidelines
• I supported continuous improvement by identifying process improvements and/or quality enhancements
• I supported the team environment and I performed other duties,as the supervisor may,from time to time,deem necessary