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, NC
Skills
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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