Customer Service Quality

Profile:

Team Leader Process Flows

Auditing -Controls Process and Matrix Leadership

Quality Organizational and Management

Business Analysis Development

Claims Troubleshooter

Customer Service

Professional Experience:

Blue Cross Blue Shield of North Carolina (BCBSNC)

05/1999-Present

Team Leader, FEP Support Operations 06/2009-

Present

. Manage day -to- day operations for one multi-functional team within

FEP Quality and Audit Support Operations totaling 7 non- exempt direct

reports.

. Maintain and approve payroll/ timesheets, for all associates as well

as allocate yearly bonuses and salary increases, Interview new

applicants for open positions

. Conduct monthly one on one session's to provide continues feedback to

staff.

. Manage daily workflow to meet deadlines. Takes appropriate actions to

follow through on all work.

. Manage the performance of quality reviews to determine the accuracy of

customer service, claims and internal and external audits.

. Participate in calibration meetings to ensure consistency in auditing

practices.

. Analyzes quality review results, identifies trends and make

recommendations to improve quality

. Provided face to face and written feedback to operational management

regarding quality reviews results to help improve individual and

overall performance.

. Maintain a collaborative relationship with other internal business

areas and management teams to improve quality and teamwork. Inform

business partners of issues that may impact their PIP etc.

. Provide an overview of quality review unit's missions, processes and

scoring methodology. Participate in call simulations during classroom

training. Provide on the job support during transition from classroom

to business area.

. Identify training needs and reports to appropriate manager within

business unit to increase quality.

. Proactively seeks out information that will allow accurate data entry,

claims processing, and resolutions for customer responses to customer

inquiries.

. Identifies and document system and process problems; reports problems

to appropriate manager. Through analysis, determines root cause and

recommends possible solutions. Communicates causes of error to others

Quality Business Analyst, Inter-Plan Support

07/2006 - 06/ 2009

. Primary Performance Guarantee(PG) Quality Assurance Analyst

. Lead Internal Rebuttal Reviewer, 2008 year to date successfully

overturned 91.18%

. Conducted Research and created stand alone documentation for external

PG Audit responses used by MPO Auditors and Group Consultants.

Prepared corrective action plans and sought permanent system and

quality (training and education) solutions to issues

. Conducted ad hoc audits requested by the PG Groups to validate

procedural and financial processing effectiveness, including report

preparation, creation, and follow up of corrective action plans

. Performed gap analysis, root cause analysis, and trending on audit

findings for continuous quality improvement and created corrective

action plans

. Compiled trends and analysis report, which tracked associate error

types and system defects

. Developed Coaching Verification Form that provided documentation of

Team Lead and Associate accountability for quality improvement

including actions taken to remediate issue

. As a Host Migration Phase III SME, performed User Assisted Testing

(UAT) and auditing of new host claims pricing process, created

training material and facilitated training of more than 150 IPP Host

Operations staff/business partners for November's Project

Implementation

. Demonstrated focus by researching the client's needs while performing

ongoing monitoring for Inter-Plan Operations (IPO) Claims and Customer

Service department.

. Performed detailed analysis of processes and productivity and

identified issues. Provided feedback on system issues pertaining to

pertinent field on ITS, PowerMHS, Magic and the Legacy system.

Remediated gaps with in processes and desk procedures

. Conducted rigorous analysis on data to adequately serve IPO. Ensured

high quality by identifying trends, produced forecasts, and suggested

ways to achieve optimum accuracy, efficiency, and customer

satisfaction.

. Improve processes; encourage better use of information resources by

Associates to yield effective customer satisfaction.

. Built strategic working relationships with IPO by hosting calibration

session for Auditors, Operational Specialist and Team Leads. Assessed

overall reported risks and prior audit finding prior to drafting audit

program-definition document.

. Developed audit programs for Customer Service and Claims organization.

. Managed and conducted coaching sessions to assist Associates with

their overall quality that led to improved customer satisfaction.

. Informed IPO Management on Customer Service Quality Monitoring results

and conducted lessons learned sessions. Provided a clear review of

financial, operational, system, process, and other relevant controls.

Conducted test steps and clearly documented findings based on value

added improvements for business.

. Developed objective, realistic corrective actions plans based on audit

findings.

. Prepared IPP's SAS- 70 process flow documentation used by external

auditors during walk through audits.

Operations Specialist, Blue Card Host Claims Department

05-2005/ 2006

. Resolved findings and prevented repeat occurrences. By investigated

and reviewed claims with issues on PowerMHS and Legacy systems.

. Conducted ongoing analysis of IPO Host Claims reports to ensure

timeliness. Monitored and reduced the 30-day claim timeliness

standard. Findings and Corrective action plans were presented to IPO

Management weekly and monthly in meetings.

. Assigned daily work to Claims Associates. Documented and presented all

completed and uncompleted work to Team Lead on a daily basis.

. Reviewed and assisted in creating all training curriculum for Claims

New Hires Classes. Trained New Hires on Submission Formant,

Disposition Formats, Reconciliation Formats on Inter-Plan

Teleprocessing systems (ITS).

. Oversaw corrected claims production area of 14-20 employees. Managed

the pre-sort department and created daily reports that would be

provided to managers. Responsible for tracking time cards, PTO. Real

time feedback to Associates, and productions goals. Conducted and

provided evaluation of Associate overall performance.

. Managed daily workflow to meet deadlines set by managers. Took the

appropriate actions to follow-through on daily work assigned.

. Worked suspends, medical records, and SIRF's regularly.

Operations Specialist Blue Card Host POS Department

03-2001/2005

Identified and understood system issues related to Host PowerMHS

claims. Upon finding system related issues collaborated with Busniess

Analyst to get issues resolved. Updated Through put Committee with all

changes involving the Point of Service Group.

Analyzed hold code processes to make sure they were applied to claims.

Suggested and made necessary changes to documents and reports for the

training department.

Manually created claims in Power MHS to the Legacy system for

processing.

. Created adjustments and refund requests from Lawson. Tracked and

closed correspondence inquires for Host Point of Service. Adjusted

Point of Service claims as required

Responded and documented provider inquiries in a timely manner.

Customer Service Specialist Blue Card Host Department

05-1999/2001

. Answered and responded to all calls in a timely and professional

manner. Assisted department in reaching overall goal of an 30 second

ASA (Average Speed of Answer)

. Researched and responded to all in coming inquires by working and

assisting the correspondence team.

. Researched claims to determine if adjustments where needed if so

performed adjusted as required.

. Advised IPO Management of any trends relevant to calls received from

providers.

Time Warner Cable Durham, NC

Customer Service Representative

08/1998- 04/1999

. Handled high volume of incoming phone calls and responded to inquiries

in a manner, that met high quality, productivity and other performance

standards.

. Sold and upgraded company core products in accordance with company

requirements and customer needs.

. Provided information regarding products and services, billing, repair,

collections and responded to other types of inquiries. Collected

customer payments and set up payment arrangements so customers would

not lose their cable services.

. Responded to customer complaints and concerns in a professional manner

along with resolution of all concerns successfully in accordance with

established guidelines set by Management.

. Completed troubleshooting for customers' service problems and schedule

field service calls when necessary. Schedule customer appointments in

accordance with established procedures.

. Made sure that all information was documented in ACSR for tracking

trending and analysis purpose.

Education:

Mt. Olive College

Expected Graduation December 2010

BA, Busniess and Administrative with a concentration in Organizational and

Development

Technical Experience:

Power MHS, Legacy, Lawson, Windows, Excel, Word, Quarto Pro, Internet

Applications, Envision, Viso, BCBS Website, IPD Suite, Power Point, Magic

Max MC, ANSIR, Witness, DOC Request.

Awards, Certifications & Recognition:

BCBSNC, Blue All Star 1,2001

BCBSNC, Blue Ribbons 12

Affiliations:

BCBSNC, Peer Leadership Committee, Member

TrueBlue Toastmaster, Member

Habitat for Humanity, Volunteer

Contact this candidate