Customer Service Process
Resume:
Chandra L. Craig
Braidwood, IL 60408
Supervisor of operations domestic and international offices, customer
oriented, succeeds in meeting or exceeding service level expectations, self
managing, strong written and oral communications skills, handles all
aspects of claims and vendor contract relationships
EXPERIENCE
DESTINY HEALTH, Chicago, IL Feb 2003 to Sept 2006
March 2007 to Present
Operations Supervisor (05/07 to present)
. Supervise operations- international and domestic- meeting or exceeding
service level agreements
. Train all processors on benefits, claims processing rules, and company
policies
. Implement and complete process improvement projects for Vice President
and Director of Operations.
. Identify error trends which improved quality of outgoing claims
. Assist manager in High dollar claim reviews
. Design and implement process improvements which reduced customer
service call issues approximately 30 to 40 calls a month
. Identify administrative duties to be transferred to Customer Response
Unit to allow an additional 20 hours for capturing team to capture for
greater production results
. Implement error appeal process which improves quality audit results by
approximately 2% per month
. Assist the appeals department on reviews based on standard insurance
practices and certificate coverage
. Create, distribute and implement all training documents
. Transitions operations functions back to Chicago office in closing the
business while remaining under budget
. Manage all issues with contracted vendors and networks
Medical Claims Review Coordinator (08/05 to 05/07, lapse from 09/06 to
03/07)
. Handle review process for claims requiring authorizations based on
plan certificate of coverage and Insurance industry standards
. Process appeal request based on plan guidelines and Insurance industry
standards
. Create training documents for adding authorizations in Magic claims
system
. Process override in Pharmacy system for member's prescriptions as
needed
. Manage all appeals submitted to vendors to meet appeal response
timeframes
Customer Care Administrator, Senior (02/03 to 07/05)
. Process hospital, vision, and medical claims according to plan
certificate of coverage benefits for large and small group
. Assist in managing wellness program
. Recovery of over $35,000.00 in third party liability recovery in less
than 18 months by implementing investigation process
. Negotiate third party liability settlements
. Audit claims completed by processors for accuracy and correct claims
payment
. Train support staff for processing hospital and facility claims.
. Process individual policy claims in accordance with certificate of
coverage, exclusions and riders.
. Support call center by answering, logging, and finalizing all calls
received.
. Manage reviews and appeal on large dollar claim audit by our vendor
. Train all staff, domestic and international, on new product, Liberty
by Tufts Health Plan-
. Review claims for benefits under plan certificate for health services
department which freed an additional 3 to 4 hours per week for health
services team
Hallmark Services, Naperville, IL Oct 2006 - Mar 2007
Claims examiner
. Review appeals and predetermination request and work with clinical
review to resolve
. Complete all claims adjustments based on appeal review determination
. Create and send all correspondence to member and provider regarding an
appeal review or predetermination review
. Maintain 99% quality or better results
UNICARE, Bolingbrook, IL Nov 1999 - Dec 2002
Recovery Specialist/ Adjustment Technician
. Handle all inquiries and overpayment recovery issue for the vendor,
Accent, increasing recoupment of overpaid funds
. Review all refund request forms for completion and accuracy Transfer
these forms electronically on a weekly basis
. Create guidelines, workflows and train staff for overpayment recovery
. Support claims adjustments, hospital audit claims processing, claims
processing, and customer service call center.
. Attend benefits fairs as Unicare representative during open
enrollment
CIGNA HEALTHCARE, Bourbonnais, IL Dec 1991 - Nov 1999
Adjustment Technician
. Handle claims adjustments for 30+ large groups.
. Create documents and train claims approvers for basic review of TMJ/
Dental improving turn around time for processing and freeing medical
review staff time
. Process claims, priority mail receipts, Hospital negotiation claims,
and other specialty claims processing to meet service level agreements
. Handle call-backs to members, providers, and internal customers as
needed due to adjustments
. Create a workflow for the CCN PPO vendor that saved the company
approximately $3,000.00 a month in overpayments.
COMPUTER SKILLS
. Type 45 words per minute
. Basic understanding of MS Office
. Cignaclaims, WGS 1.5, and Magic claims processing systems
. Rumba and Compass pharmacy systems
EDUCATION
College of St Francis Journalism
Iowa Wesleyan College Communications
Reed Custer High School Diploma 1985
ORGANIZATIONS
. Relay for Life committee chair
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