Leadership expertise with ability to effectively train and manage confident employees.
* Credited with developing and implementing strategies to improve service, increase sales, improve productivity and reduce unnecessary spending
* Ability to organize and prioritize tasks with attention to quality, detail and deadlines.
* Proficient in Microsoft Word, Excel, PowerPoint, Outlook and Internet; possesses computer engineering skills.
Microsoft Office Word, Excel, Access, PowerPoint, and Project
Business Objects InfoView
Physician Cost Model v6.0
Teradata SQL Assistant
Siebel Service 1st - PROD 8.1
LexisNexis - Intelligent Investigator
LexisNexis - SIRIS
PowerMHS - PROD - 7.3
Blue Cross Blue Shield of North CarolinaDurham, NCInvestigator07/2014 to Current
Analyze and investigate allegations of healthcare fraud, waste, and abuse from various sources including, but not limited to online email complaints from providers and members; as well as internal BCBSNC departments and outside government agencies.
Identify aberrant billing patterns or trends by using internal and external data that may highlight potential behaviors in the provider's billing.
Conduct investigations through research; using claims data resources and anti-fraud software, medical records, case management documentation, and/or conduct interviews with related parties.
Document Manage investigative steps in a clear and concise manner within the case tracking tool and system.
Create detailed case summaries in executive summary format, for presentation to management, providers and other parties as necessary.
Develop Develop recommendations for corrective actions to management, internal departments and client to improve provider billing outcomes.
Maintain continuous broad based knowledge of BCBSNC products, claims systems, benefits administration, reimbursement policies, and contractual agreements of providers, membership, enrollment and data systems.
Senior Team Leader06/2013 to 07/2014
Managed day-to-day operations ofteam of winning professionals for the provider onsite service model for Duke University Healthcare System (DUHS) while providing leadership and direction to dedicated staff on establishing goals and meeting service expectations.
Influenced senior management when making multiple decisions for Served as a subject matter expert for the Operations department on corporate projects related to data management.
Identified and delegated escalated, complex high dollar operational claim issues for resolution.
Identified opportunities for controlling medical expense and deploy action plans to accomplish stakeholder-specific or regional medical expense goals.
Provider Service Consultant01/2007 to 06/2013
Provided optimal operational support to various healthcare systems and providers in Eastern North Carolina.
Maintained updated Standard Operating Procedures (SOP) for day-to-day procedures with various healthcare providers and internal customers.
Made recommendations; which led to implementation and/or enhancing processes with data integration and data quality.
Initiated proactive meetings with providers and internal BCBSNC customers to gauge satisfaction and to identify opportunities for improvement.
Conducted presentations in an effort to educate statewide providers on BCBSNC system enhancements, operational processes, policies and key messages through monthly service-focus meetings, provider training workshops, annual BCBSNC provider conferences, and various healthcare forums.
Claims Specialist02/1999 to 07/2007
Researched and resolved pended claims; which included completing adjustments, submission of refund requests to providers and processed facility and professional claims.
Served as a subject matter expert for employees' inquiries around work process, procedures, products, policy, etc.
Trained and audited new hire employees.
Handled special projects as necessary; created and reported on project data analysis.
Bachelors of ArtMay 2014North Carolina Wesleyan College Marketing
Bachelors of Art:Business AdministrationMay 2014North Carolina Wesleyan CollegeBusiness Administration
Certified Professional Coder (CPC) American Academy of Professional Coders (AAPC) September 2008
benefits administration, billing, Business Objects, case management, concise, conferences, client, data analysis, data integration, data management, direction, documentation, email, senior management, Financials, focus, government, Lawson, leadership, meetings, Access, Excel, Microsoft Office, PowerPoint, SharePoint, Word, policies, presentations, processes, quality, research, Siebel, SOP, SQL, Teradata, workshops
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Companies Worked For:
Blue Cross Blue Shield of North Carolina
North Carolina Wesleyan College Marketing
North Carolina Wesleyan College
Job Titles Held:
Senior Team Leader
Provider Service Consultant
Bachelors of Art May 2014 Bachelors of Art : Business Administration May 2014
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