Customer Service Quality Assurance

*** ****** ***** *****

Drive 803-***-****

Columbia, SC E-mail

***** **.*******@live.c

om

Sheila Smith Baxley

Objective To obtain a position that will both utilize and

enhance my current skill sets that will benefit the

company and hopefully afford myself opportunities

for career advancement within the company.

Education 1978 - 1981 Myrtle Beach High School Myrtle Beach,

SC

High School Diploma

Work experience 1994 - 2010 Blue Cross Blue Shield of SC Columbia,

SC

Project Administrator I / January 2007 - April 2010

I performed duties of an Outreach Coordinator. I

had to make and receive calls from and to members

that were terminally ill. I made sure that any

issues surrounding claims activity were resolved

correctly and in a timely manner.

I created and ran reports for the department

director t identify trends within the department

that needed to be addressed that would potentially

improve productivity.

I had to perform special projects that were

assigned to me. Claims issues that were brought to

my management's attention had to be researched. I

had to research the identified patient's entire

claims history and issue corrective action on all

claims found to be in error.

I trained Member Service Representatives (MSRs) on

the proper procedures to follow and where to find

information regarding questions from members

calling into the customer service center.

Claims Review Coordinator / December 2003 - December 2006

. I performed duties of an Outreach Coordinator. I had to

make and receive calls from and to members that were

terminally ill. I made sure that any issues surrounding

claims activity were resolved correctly and in a timely

manner.

Project Testing Coordinator / September 2001 - December

2003

. I tested system changes for the TRICARE For Life program

prior to the changes being implemented.

. I developed test matrices to support both positive and

negative testing scenarios to identify any issues with

system changes made prior to implementation.

. I monitored the production environment once system

changes were implemented and reported any issues to the

project team for resolution.

. I loaded testing scenarios and results into an access

database and ran various reports to identify percentages

complete, tested, and approved.

. I served as the lead tester for various mandates from

TMA.

Quality Assurance Analyst I / May 1996 - September 2001

. I was on the External Audit team. I put together audit

packages that had to be sent to TRICARE Management

Activity (TMA) to justify why and how claims were

processed. I had to rebut audit errors assessed and

provide documentation to support the rebuttal.

. I also performed the role of Duplicate Claims System

analyst. Any TRICARE claims that were processed by

multiple contractors had to be researched to make a

determination if the provider or beneficiary had been

paid more than once for the same claim. If it was

determined that duplicate payments were made, I

coordinated the effort to regain monies that should not

have been paid.

. I conducted pre-payment audits on all claims where the

payment was equal to or greater than $100,000.

Claims Associate II / February 1994 - May 1996

. I processed claims for TRICARE.

. I worked claims edits to ensure claims for TRICARE were

processed according to policy and procedures. I worked

Third Party Liability claims, DME/PEN claims, and Home

Health Claims.

. I conducted reviews on high dollar claims to ensure

accuracy.

Awards Received I received my certification to run DB2 queries and

EZTrieve programs from Blue Cross Blue Shield of

SC.

References Available upon request

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