Kimberly Gates

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

Roanoke, VA *4015

540-***-**** (cell)

ac2ofz@r.postjobfree.com

QUALIFICATIONS SUMMARY

Award-winning, dedicated and productivity-focused Operations Expert with 9+ years’ experience in claims processing. Offers outstanding talents in customer service and team relationships, mentoring, and quality assurance. Highly motivated case researcher driven by desire for timely resolution of complex claims. Collaborates with all levels of management and staff to remove impediments to optimum cycle time. Excellent customer and team interaction. Considered a subject matter expert and primary resource for claims processing and technical inquiries. Immensely enjoys all aspects of coaching, mentoring and developing talents from individuals. First line resource for technical direction, guidance and resources for customer service and satisfaction. Coordinates associates to ensure that they have the information and support they need to encourage collaboration and synergy. Provide understandable feedback to associates regarding production and team metrics. Monitor workflow changes to ensure associates understanding. Harmonious conflict resolution. Support training and on-boarding of new associates and associates learning new skill sets and support functions. Regular management reporting and monitoring of metrics to ensure learning objectives are attained and resources are properly allocated. Assist in creating and updating training documents. Conduct public speaking and training events.

CORE COMPETENCIES

Policy / Procedure Interpretation and Rollout Medicare Benefits Verification Via Litton Mentoring

Management Reporting and Analysis New-Hire and Upskill Training Process and Policy Adherence

Specialty Claim Processing Regulatory Compliance Blue Link Proficiency Audit MS Office

Process Management Legal Documentation Quality Assurance Quality Control

EXPERIENCE HIGHLIGHTS

ANTHEM BCBS, Roanoke, VA Operations Expert July 2008 – Present

Provide technical direction, guidance and resources to associates in Claims and Customer Service. Serve as front line point of contact for Operations Review quality errors including: disputes, interpret actions, educate representatives, report escalated issues. Provide daily feedback to associates regarding production and team metrics. Facilitate one on one mentoring and coaching with representatives. Monitor and conveyAdminister BCBS Benefits for the Federal Employee Program. Ensure compliance with all policies and procedures of the Federal Employee Program and Anthem BCBS. Assure Federal Employee Program customer satisfaction through telephone and email communication, referral to physician & pharmacy services, claim and claim follow-up. Manage Specialty Claims processing, focusing on eliminating duplicate claims and timely resolution of deferred claims. Train new-hires for entry-level CSR duties. Conduct upskill processing procedures training for CSRs in conjunction with Experts, Training Facilitators, Workforce Management, Auditors, Business Analysts, Process Experts and Grievance and Appeals. Review service level of Pending Inquiries Queue; prepare and distribute report to Operations Experts and management to ensure cycle time is met. Sole accountability for Medical Review Deb Dearing specialty pending location. Review all changes to process and regulations updates; prepare summaries; disseminate to team, ensuring efficient assimilation into routine workflow with least negative impact to productivity. Handles escalated calls and claims issues including Supervisor Calls including inquiries from the Department of Insurance, Legal, Executive Concierge, and Provider Relations areas. Prepare concise and accurate written documentation of telephone interactions with members and providers. Communicate with management and Operations Experts on a daily basis focusing on the Facility Aged and Specialty Report reviewed by the Vice President of Operations. Proficiency in Specialty Facility claim processing, including resolution of all pending Facility and specialty deferral claims.

Ensure accuracy of Coordination of Benefits information. Regular inclusion of Club FEP, multiple-time winner of Best In Class Award. Ensure all systems are operational and working efficiently to support associates, direct resolution of system and printer issues, reporting system outages, and troubleshooting desktop issues. Monitor floor activity to ensure active participation from associates.

CCS MEDICAL, Roanoke, VA Documentation Specialist March 2006 - July 2008

Ensured customer satisfaction through written and verbal communication with physician's offices and pharmacies; conducted training of new hires and audits of internal workflow process claims and filings; performed quality reviews; performed error remediation and/or claim filing issues; liaised with pharmacy and provider offices for efficient prescription service; responsible for HIPAA compliance and regulations.

WACHOVIA BANK NA, Roanoke, VA Bankruptcy Specialist II April 2001 - March 2006

Responsible for $49M real estate portfolio; directly communicated with law professionals and paralegals to negotiate the profitable resolution of delinquent property contracts. Specialized in Chapter 7 bankruptcy proceedings, including asset recovery and negotiation for delinquent accounts; utilized proprietary software tools to ensure accurate filing of all documents.

EDUCATION

NATIONAL BUSINESS COLLEGE, Roanoke, VA

Associate’s Degree Travel & Tourism, June 1992

Studied travel industry with minor in marketing and accounting;

Graduated with Academic Honors

Achieved 3.96 cumulative GPA of possible 4.0

VIRGINIA WESTERN COMMUNITY COLLEGE, Roanoke, VA

Completed coursework in School of Social Work, June 2012-2013

Earned 6 credit hours, 4.0 GPA of possible 4.0

AWARDS/RECOGNITION

Award-winning customer service skills and productivity rate (Anthem, CCS, Wachovia)

Aspiring Leadership Fundamentals Program Scholar 2017

Continuous Process Improvement Scholar 2017

Recipient of Values in Action Award 2016

Who’s Who in Junior Colleges in America 1992

Hurn Scholarship for Academic Excellence Recipient 1992

EM Coulter award for Outstanding Leadership Skills 1992

VOLUNTEER ACTIVITIES

Provide mentoring and life coach support to women beginning and continuing life in abstinence from addiction through programs at the Roanoke Rescue Mission and Bethany Hall 2001 to present

Frequent speaker on topics of interest to Roanoke area recovering community 1999 to present

Facilitate meetings of local recovery community, including Roanoke City Jail and Western VA Regional Jail 2011 to present

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