Waynetta M. Harris
Durham,NC
Summary
Seasoned professional with more than twenty years of experience in the insurance field. Team player that demonstrates initiative and good judgment without supervision and functions well under pressure. Delivers 100% customer focus at all times. Looking to secure a challenging position that will provide career growth.
Overview
22
22
years of professional experience
Work History
Medicare Secondary Payor/MSP Specialist
Blue Cross Blue Shield of North Carolina
03.2023 - Current
- Resolve Medicare Secondary Payor (MSP) demand letters issued by the Center for Medicare/Medicaid services (CMS)
- Review and provide initial response to MSP demands
- Serve as a Subject Matter Expert for inquiries, processes, and procedures
- Document all transactions related to each federal case in the MSP tracking database
- Place phone calls to the US Department of Treasury, the Medicare Secondary Payor Recovery
- Work directly with group administrators to provide detail status on all demand issues and obtain information necessary to responds to MSP demands
- Accountable for the full resolution of the demand, including through claims research, documentation, claims adjustments, and issue special checks
- Contact MSPRC or collection agencies to expedite reviews and resolve issues
- Consult with internal legal departments to resolve problematic demands.
Operation Specialist
Blue Cross Blue Shield of North Carolina
04.2013 - 04.2023
- One-on-one training, auditing, fulfillment, and /or root cause analysis
- Identified and document escalated, recurring or complex system and process problems
- Interface with project teams to resolve these complex issues
- Provided service as a subject matter expert for employees inquires around work process, procedures, products, policies
- Developed and maintained reports (i.e., team level, inventory) on a daily, or as required basis
- Identified problems, gaps, or inconsistencies in workflows, and /or process: recommend updates, alternatives, and/or solutions
- Function as a point of contact for internal and /or external audits and projects as necessary: assist in planning, scoping, testing, training, and implementation
- Placed outbound calls to various providers, customers, or other outside contacts
- Monitored and evaluate operational processes and interactions for quality assurance purposes as requested
- May perform quality reviews of operational inquires to determine the accuracy of information provided and ensure employees are functioning at the expected level of service to enhance customer interaction
- Communicate the results of the reviews to improve individual and overall performance and make recommendations for coaching and training, as necessary
- Managed special projects as necessary: create and report on project data analysis
- Work escalations and DOI’s from customer service and upper management
- Complete audits on Source HOV, Excel 300-500 audits monthly
- Complete audits on team members about 50 to 100 monthly.
Front End Claims Specialist/SME
Blue Cross Blue Shield of North Carolina
06.2001 - 04.2013
- Responded promptly and accurately to inquiries received from Customer Service Specialists, subscribers, providers, and other commercial insurance carriers regarding claims payments
- Researched HFCA inquires for Providers for payments, and process Siebel and IPD Inquires
- Managed Medicare, Medicaid, and Third-Party payments
- Processed and priced HMOs (Home Care System) hospital, office, and lab visits
- ICD-9 coding
- HCPCs coding, and CPT coding
- Corrected and processed electronic suspends errors, for different types of Health Insurance coverage (Blue card, Local, New Blue, Medicare, DME, and Dental)
- Communicated effectively to customer service and Health Care providers to verify membership eligibility, health coverage, and various membership errors
- Identified and documented system and process problems: reports problems to appropriate manger
- Through analysis, determines root cause and recommends workable solutions, and communicates causes of errors to others
- Mornings reports and keep count of workflow daily
- Managed daily workflow to meet deadlines
- Take appropriate actions to follow through on all work
- Maintained confidentiality of business and personal information, in compliance according to HIPAA
- Regulations.
Education
High School Diploma -
Durham High School
Durham, NCSkills
- Claims Adjustment
- Customer Experience
- Customer Focus
- Multitask
- Team Player
- Effective Communicator
- Researcher
- Detailed Oriented
Affiliations
- NextNet - For what's next in work and life
- VetNet Veterans Network
- AABEN African-American/Black Employee Network
Volunteer Work
- Backpack Buddies
- Blue Escape
- Ronald McDonald House
Timeline
Medicare Secondary Payor/MSP Specialist
Blue Cross Blue Shield of North Carolina
03.2023 - Current
Operation Specialist
Blue Cross Blue Shield of North Carolina
04.2013 - 04.2023
Front End Claims Specialist/SME
Blue Cross Blue Shield of North Carolina
06.2001 - 04.2013
High School Diploma -
Durham High School
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