STANLEY JEROME ROBERTS

**** ****** **., ************, **. 32205

904-***-****

E-mail: abygli@r.postjobfree.com

Career Objective

In developing a new career for myself, my objective is to join a firm that has a professional atmosphere, and encourages

their employees to be creative and discover new opportunities.

My preference is to obtain a position that will allow me to utilize all my skills: Office support, Human resources,

Research, Appeals and Grievances, Security expert (U.S. military (NAVY), and CSC. NFL. Systems Tester (IT) Case

Support Specialist, Health Insurance Advocate, or customer service. I am a fast learner, self starter, dedicated to my

work, and always ready to take on a new task. I would be a great asset to your company.

Work History

BroadPath Inc., Tucson, Arizona

October 2012 to April 2013 Job Title: Appeals Specialist/Proof Reader

(National Government Services PA)

MEDICARE/MEDICAID

• Duties: Proof read customer and provider appeals letters regarding provisions of service and benefit

coverage, and claim issues and resolutions.

• Ensures appropriate punctuation, grammar, format, and alignment of appeals letters before letters

are mailed to recipients.

• Sent with corrections and other resolutions to appeals representatives within specified timeframes for

corrections and to management for records and training.

AEROTEK Inc., Cincinnati, Ohio

October 2011 to April 2012 Job Title: Appeals & Grievance Specialist (Anthem

BCBS Ohio) MEDICARE/MEDICAID

• Duties: Investigates and reviews customer and provider grievances and appeals regarding provision

of service and benefit coverage issues.

• Triages clinical and non-clinical inquiries, grievances and appeals, prepares case files for member

grievance committees/hearings. Summarizes and presents essential information for the clinical specialist or

medical director and legal counsel. Responds to oral and written complaints.

• Ensures appropriate resolution to inquiries, grievances and appeals within specified timeframes

established by either regulatory/accreditation agencies or customer needs. Contacts customers and providers

to gather information and communicate disposition of case and document interactions .

BroadPath Inc., Tucson, Arizona

October 2009 to October 2011 Job Title: Service Professional (CIGNA

TN/CIGNA TX) MEDICARE/MEDICAID

• Duties: Assist clients with new and ongoing projects. Expert in the Health Insurance industry.

Answer questions regarding Medicare claims, status, eligibility, and coverage. Verifying if claim priced

correctly, speak with providers about claims and status. Worked special projects for client to have

outstanding issues researched and resolved. Advanced knowledge of products and services. Research and

resolve problems using resources provided by company. Delivered and resolved service inquiries, improved

benefit communications, claim and member services and billing resolutions.

• Provide customer service for various participants within various managed care programs including

members, providers, internal departments, covering topics such as claim status, eligibility, coverage, appeals

and general provider/member inquiries.

• Perform claim review to assure accurate processing and/or to establish reprocessing of claims and

performed audits to ensure the highest level of integrity with claim processing, correspondence, and customer

service requests.

The Jacobson Group, Chicago, Illinois

September 2008 to October 2009 Job Title: Service Professional (ANTHEM OH)

• Duties: Assist clients with new and ongoing projects. Expert in the Health Insurance industry.

Delivered and resolved service inquiries, improved benefit communications, claim and member services and

billing resolutions.

• Provide customer service for various participants within various managed care programs including

members, providers, internal departments, covering topics such as claim status, eligibility, coverage, appeals

and general provider/member inquiries.

• Perform claim review to assure accurate processing and/or re-process(claims adjustments) claims

and performed audits to ensure the highest level of integrity with claim processing, correspondence, and

customer service requests.

• Perform configuration to facets for Claims/Provider’s to be paid accordingly.

• Review provider/member formal/informal appeals and grievances within compliance of state laws.

PerotSystems, Plano, Texas

February 2008 to September 2008 Job Title: Service Professional (BCBS CO)

• Duties: Assist clients with new and ongoing projects. Expert in the Health Insurance industry.

Duties: Assist clients with new and ongoing projects. Expert in the Health Insurance industry. Delivered and

resolved service inquiries, improved benefit communications, claim and member services and billing

resolutions.

• Provide customer service for various participants within various managed care programs including

members, providers, internal departments, covering topics such as claim status, eligibility, coverage, appeals

and general provider/member inquiries.

• Perform claim review to assure accurate processing and/or to establish reprocessing of claims and

performed audits to ensure the highest level of integrity with claim processing, correspondence, and customer

service requests.

• Perform configuration to facets for Claims/Provider’s to be paid accordingly.

• Review provider/member formal/informal appeals and grievances within compliance of state laws.

The Jacobson Group, Chicago, Illinois

September 2007 to September 2008 Job Title: Service Professional (BCBS KS)

• Duties: Assist clients with new and ongoing projects. Expert in the Health Insurance industry.

Delivered and resolved service inquiries, improved benefit communications, claim and member services and

billing resolutions.

• Provide customer service for various participants within various managed care programs including

members, providers, internal departments, covering topics such as claim status, eligibility, coverage, appeals

and general provider/member inquiries.

• Perform claim review to assure accurate processing and/or to establish reprocessing of claims and

performed audits to ensure the highest level of integrity with claim processing, correspondence, and customer

service requests.

• Perform configuration to Facets for Claims/Provider’s to be paid accordingly.

• Review provider/member formal/informal appeals and grievances within compliance of state laws.

Blue Cross and Blue Shield, Jacksonville, Florida

January 2005 to January 2007 Job Title: Service Advocate II

Duties: Assist Medicare Beneficiaries with Medicare benefits. Explain eligibility, Medicare Prescription Drug Program,

Covered/non-covered procedures, Use of the Social Security Web-Site and Medicare Web-Site to assist beneficiaries in

ordering medicare cards/replacement cards, Prescription Drug Cards, Membership enrollment.

• Process and adjust claims according to plan procedures and policies.

• Perform claim review to assure accurate processing and/or reprocessing of claims and performed

audits to ensure the highest level of integrity with both claim processing, correspondence, and customer

service requests.

• Answer questions regarding claims, status, eligibility, and coverage, provider relations, benefits and

enrollment, Advanced knowledge of products and services.

• Research and resolve problems using resources provided by company. Follow-up with providers and

members regarding claim and eligibility and adjustments status via call backs or correspondence.

• Delivered and resolved service inquiries, Membership enrollment, improved benefit communications,

claim and member services and billing resolutions.

• Provide customer service for various participants within various managed care programs including

members, providers, internal departments, covering topics such as claim status, eligibility, coverage, appeals

and general provider/member inquiries.

Citistreet Inc, Jacksonville, Florida

January 1998 to February 2004 Job Title: Benefit Analyst

Duties: Perform pension calculations, research, troubleshoot, and resolve cases for participants, retirees and surviving

spouses’ pensions. Provide all facets of quality customer service through prompt call backs and answering incoming

calls. Research, create, audit, and send surviving spouses and beneficiaries’ death benefits, survivor monthly payments,

and health & welfare benefit information. Research, and resolve appeals and grievances. Contact clients to review status

of audit and benefit overpayments. Create and send letters to collect overpayments. Create spreadsheets, files, and

forms to utilize as tools of organization. Accessing the State Street Global Advisory Payroll System to verify participant

and beneficiary payments sent to them via check or electronic funds transfer; also using a second application of the

same system to verify payment status. Request stop payments, re-issue checks by use of unique application of

Wellspring Resources program. Assisted the IT department with implementing and testing new and re-configured

systems and applications to ensure quality and integrity.

Prudential Healthcare Inc., Jacksonville, Florida

December 1996 to January 1998 Job Title: Dental Member Services Specialist

Duties: Provide all facets of quality customer service through assisting, verifying, and enrollment/updating dental

membership, eligibility, and claims within a call center environment.

Verified claims information for accuracy. Reprocessed claims if errors found in original processing.

AT&T American Transtech, Jacksonville, Florida

August, 1995 to December 1996 Job Title: Benefit Specialist III/BDEC

Duties: Consist of analyzing, research, investigate, and resolution of inquiries pertaining to eligibility and enrollment of

employees, retirees, and eligible dependents. Provide customer with detailed information concerning products and

services. Determine the appropriate action required to resolve problems and coordinate resolution with employees,

retirees, or other internal/external sources. May require the calculation of data to support account adjustments. Enter

description of action taken or transaction into database. Respond to request by preparing system generated or custom

letters. Carrying the title of Case Worker, my major responsibilities were to research, investigate and resolve employees,

retirees, and dependent benefit problems. Under general supervision, respond to inquiries or process transactions of

legal, technical, or mechanical nature. Procedures to address each situation varied substantially from call to call and

were not always clearly defined for all situations. Guided by plan documents or principles of discipline.

AT&T American Transtech, Jacksonville, Florida

October 1987 to August 1995 Job Title: Customer Service Rep II/Business Services

Duties: Responsibilities included handling orders to switch, add, or enhance customers’ business’ long distance

services to and for AT&T. Research and verify long distance carriers and rates. Perform data entry duties to assure that

orders were provisioned by deadlines, also adhering to formulated script when applicable and handling fluctuating

volumes for four to five different projects while meeting productivity and quality standards.

United States Navy/AKRON 55, NAS Oceana VA Beach, Virginia

August 1983 to August 1987 Job Title: Naval Aviation Administration

Duties: Responsibilities included various government tasks, of classified and non-classified activities. Handling,

typing, filing, creating and implementing military directives, letters, correspondence and narratives which are vital to

normal operation of military commands. Obtained the title of supervisor for two years, in which I supervised 12 airmen

for various military assignments, meeting goals and deadlines. Providing standard and high security duties to secure

squadron aircraft, personnel, equipment, and documents.

Education

ROBERT E. LEE Senior High School, Jacksonville, Florida

Academics, Business Math, and Accounting / Graduated June 1983 (Diploma)

HERITAGE COLLEGE, Jacksonville, Florida

1. 900 hours Massage Therapy: Theory, Business, Practical, and Clinical Applications, Human

Anatomy/Physiology, Kinesiology, Pathology, Assessment and practice, Adjunct techniques and methods /

Graduated April 2004 (Diploma/certificate).

Special Skills

10 KEY EIP MAIN FRAME POWER POINT

1ST CHICAGO NBD PAYROLL ENTERPRISE TRANSACTION MEDICAL ASSESSMENTS RBMS

SYSTEMS MANAGEMENT

ACCESS EVT PEOPLE SOFT SEIBEL

BDS JAX, B-2000, IDCP, EXCEL MICROSOFT SUITES STATE STREET GLOBAL

ASSET, CRT ADVISARY PAYROLL

SYSTEMS

ON DEMAND

BLUE 2 FACETS SYBASE AIMSPR001 TRIZETTO

CICS GP00 NASCO C/S ULTERA FILNET CENTRAL

CLAIMS REPOSITORY IMS NETWORX CLAIMS PRICER UNIFIED NETWORK

MARX

CLIENT LETTER INTRA/INTER NET WGS CALL CARE

GARD/BPM

WSCS MCS

CONVERGENCE X ITFI ONNET 2.0 BPM

DIAMOND LOTUS PENSION PAYROLL SYSTEM WCF / WGS

I HEALTH

EBT NEXT-GEN SHAREPOINT

MEDISYS

MAS Toolbar CITRIX UPS

References Available Upon Request

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