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Associate Claim Processor/Member Service Advocate Resume Example

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ASSOCIATE CLAIM PROCESSOR/MEMBER SERVICE ADVOCATE
Summary
After 29 years' of working in an industry that puts people at the forefront of their business, I have a proven track record of building and maintaining relationships and an impeccable customer service background. My objective is to continue to put people first, build strong and long last relationships and to use my expertise in the customer service field, to give the customer an exceptional experience. 
Skills
  • Customer service
  • Verbal and written communication
  • Team collaboration
  • Problem solving and decision making
  • Strong Analytics
  • Strong work ethic
  • Working independently and in a team environment
  • Strong leadership
  • Interpersonal skills
Experience
05/2013 to Current
Associate Claim Processor/Member Service AdvocateHighmark Blue Shield － Wilmington, DE
  • Receive calls from customers regarding coordination of benefits
  • Respond accurately and promptly to customer concerns
  • Update system with additional insurance information
  • Initiate calls to providers to verify or request additional information required for accurate processing
  • Keep records of customer transactions and detail comments of inquiries
  • Organize customer inquiries to meet specific time frames
  • Examine new claims for pertinent information required for initial claim entry.
  • Evaluate and apply policies and procedures implemented for the processing of claims.
  • Review and execute request from internal departments,  providing feedback on findings
  • Research and execute adjustments on claims processed incorrectly
  • Resolve claim suspends by using the proper reference guides and systems for resolution.
  • Accountable for researching history records when determining claim processing issues and providing claim status to the lead processor and supervisor
  • Review claims for Coordination of Benefits with Medicare, Medicaid, and other insurance carriers
  • Collaborate daily with supervisor's, team leads and team members, to provide exemplary service to our customers
07/2011 to 05/2013
Claim ProcessorBlue Cross Blue Shield of Delaware － Wilmington, DE
  • Evaluated new provider and customer claims for information required for processing.
  • Identified claim discrepancies and determined appropriate resolution in processing.
  • Determined if claims should be returned, denied, or adjudicated based on policy and procedure manuals.
  • Trained temporary staff and new hire employees on claim processing, policies and procedures, and system applications.
  • Provided feedback to management regarding the progress of temporary staff and new hires and gave additional training and assistance where needed.
  • Reviewed and resolved claim inquiries regarding under/overpayments, benefits, pricing and rate issues.
  • Manually priced claims based on provider contract and required information.
  • Participated in and tested new systems during implementation and configuration of Highmark applications prior to turnkey.
  • Evaluated and tested new or managed care software programs and development procedures used to verify that programs function according to user requirements.
  • Performed plan testing and produced status updates to management.
  • Systems used: TBS, BlueChip, IDM, ITS/Formats, BlueSquared, OCR.
07/2010 to 07/2011
Customer Service RepresentativeBlue Cross Blue Shield Delaware － Wilmington, DE
  • Managed customer and provider calls regarding benefits, eligibility and claims.
  • Reviewed benefits for understanding of applications and benefits.
  • Requested identification cards and Certificates of Credible Coverage.
  • Collaborated with providers in resolving claims issues in an effort to provide excellent service to our members.
  • Provided timely resolution and callback to provider's and customers regarding concerns.
  • Assisted members with online navigation of the BCBSDE website and assisted providers with NaviNet.
  • Systems used: TBS, BlueChip, IDM, ITS/Formats, Avaya Phone system.
01/2008 to 07/2009
Team Lead/BlueCard Host AdjustmentsAnthem Blue Cross Blue Shield of Ohio/Dell － Columbus, OH
  • Provided subject matter direction to team members and assisted with complex claim issues.
  • Educated team on new claim processes, new and updated procedures, and system updates.
  • Performed audits on randomly selected letters sent to provider's.
  • Provided assistance to the supervisor by managing workflow and delegating work based on expertise.
  • Reported systems issues and benefit discrepancies to IT and configurations analyst.
  • Developed and modified letters to providers and contacted Home plans regarding claim issues.
  • Participated in compiling production reports and timesheets for management.
  • Reviewed and responded to inquiries from providers and BlueCard plans requesting adjustments to claims that were underpaid or overpaid.
  • Maintained production and quality standards.
  • Systems used: WGS, Inter-plan Messaging, Facets, ETM, Ultera, NetWorx, Citrix.
04/2007 to 01/2008
EDI Enrollment SpecialistIndependence Blue Cross － Philadelphia, PA
  • Identified and resolved discrepancies on enrollment applications and group transmittals.
  • Processed request for additions, changes, reinstatements, and terminations.
  • Requested additional information as needed from marketing representatives, groups, and members.
  • Analyzed group enrollment forms for rate and tier changes, and updated MHS, Facets, MSIQ, and SLIQ.
12/2005 to 04/2007
Underwriting AssistantBlue Cross of California － Woodland Hills, CA
  • Acted as a liaison to verify, research, track and monitor specific case issues.
  • Prepared information into MGU from specific, aggregate, benefits, and census reports.
  • Reviewed census, specific, and aggregate reports for correct calculations.
  • Followed up with client request and acted as a liaison for the customer and underwriter.
  • Provided support to underwriters in the quotation process for new business.
  • Gathered and input data into Sales and Underwriting systems to monitor and track quote activity.
Education and Training
Present
Behavioral ScienceWilmington UniversityBehavioral Science
1988
AccountingFranklin Morris Business AcademyAccounting
1983
Diploma: General StudiesJohn W. Hallahan Catholic High SchoolGeneral Studies
Skills
analyst, Avaya, Benefits, Citrix, client, direction, forms, IBM, insurance, letters, mainframe, managing, marketing, Messaging, SharePoint, navigation, OCR, Phone system, policies, pricing, processes, progress, quality, researching, research, Sales, supervisor, underwriter, Underwriting, website, workflow
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Resume Overview

Companies Worked For:

  • Highmark Blue Shield
  • Blue Cross Blue Shield of Delaware
  • Blue Cross Blue Shield Delaware
  • Anthem Blue Cross Blue Shield of Ohio/Dell
  • Independence Blue Cross
  • Blue Cross of California

School Attended

  • Wilmington University
  • Franklin Morris Business Academy
  • John W. Hallahan Catholic High School

Job Titles Held:

  • Associate Claim Processor/Member Service Advocate
  • Claim Processor
  • Customer Service Representative
  • Team Lead/BlueCard Host Adjustments
  • EDI Enrollment Specialist
  • Underwriting Assistant

Degrees

  • Behavioral Science
    Accounting
    Diploma : General Studies

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