Customer Service Manager

Betty Elerby-Beemon CPhT, BSHA. MISM, LSS, PM (Ed.D)

*** ********** ******, *****, ** 78634 * Home: 512-***-**** * Cell: 512-***-**** * Work: 888-***-****

********@*****.***

Professional Summary

I hold a MBA in Business Administration and Information System Management, Bachelor’s in Health Service Administration and working toward my PhD in Organizational Leadership Management. I have 30 years’ in Health Care with 22 years in Health Care Management. Also an extended background in the following fields Customer Service, Employee Benefits, Master Data Management (Enterprise Data Lakes software), Project Management, Contracting, Provider Relations, Insurance Property Claims, Health Insurance (Government and Commercial), STD and LTD, Workers’ Comp, Managed Care Systems, Dural Medical Equipment (DME), Data Analytics, Information Technology/Electronic Data Integration (IT, EDI) including knowledge of AS2, FTP and SFTP, handling requests and identifying all request aspects EDI activity. Operations Support, Rational Tools (Certificated). In addition, Medical & Pharmacy Claims, PBM Solutions, Prior authorization, Appeals, and Reconsideration with an ITIL v3, Six Sigma Methodology.

My current responsibility as a Project Manager for Process Improvement manages and supports the development of new or improves process throughout the Army Headquarter MEDCOM Business Office. My position working in an information Technology environment where I lead several a project consisting of design and build a solution that creates and enhances the business flow operations. Experienced Project Manager with five-year’ experience in project planning, implementation and execution and proven ability to support multiple projects with medium to high complexity. Part of my responsibility was to enhance SharePoint and build programs applications so that the data is visible and accessible to the entire MEDCOM Headquarters. I have a keen knowledge of Microsoft project and office; Information Technology application, systems, and processes; Resource Management policies and practices and change management techniques with an ITIL and Six Sigma Methodology.

Prior experience helps team developers, and other department heads, testing, troubleshooting. Experience with IBM Rational Concert Configuration and Change Management; Rational Quality Management, Rational DOORS Next Generation Requirements Management; Excellent Knowledge in ANSI and X12 Standards and HIPAA. Familiarity with XML standards SQL, SAP, SAS platform, Visio, Dashboards and Service Desk Manager (DSM) ticketing system; clear understanding of 277, 278, 834, 835, 837, 810, 850, and 856; WAP, TA1/999, 277CA. A strong understanding of HIPAA, HCPC, CPT, ICD 9 conversion ICD 10 and EDI solution for clients’ eCommerce, health and financial claims management, eligibility, provider, and reporting.

Consistently achieving high satisfaction rankings, and over performing turnaround times and a respected team builder and leader with a customer-focused team; installs a shared, enthusiastic commitment to customer service internal and externally. Uses time effectively to ensure that business operation assignments are complete. Develop procedure policy improvements with an ITIL and Six Sigma Methodology. I have also taken key roles in improving compliance and training according to policy. Participate in SWOT, incident/ critical incident management, and disaster recovery. I handle special projects and SME of the following tactics: mentoring, directing, training, supervising overall department functions and staff of customer service operation, giving personal interaction, and resolving varies complex issues and employee disciplinary action as necessary and the following levels of Health Care:

Provider Relations and Resolution Team Building and Training Mgt. Hospice/Respite Care/DME Management

Project Management Worker’s Compensation Management Data Management Analytics

Business/Functional Analyst Product Margin Improvement EDI System Administrator

Claim Management STD/LTD Benefits Management Cost-Reduction Strategies

Account Management Appeal, Referral, & Reconsideration Mgt. Customer Service Management

Career Summary and Highlights

Idea Entity/Contract HQ MEDCOM Business Office June 2017 to Nov 2018

2748 Worth Road, Suite 19

FT. Sam Houston, TX 78234

Chris Flores, COR, 210-***-****

Aaron Robinson, Exec. Admin, 808-***-****

Damon Collier, Manpower Manager, 210 854,6955

Worked as a Project Manager for Process Improvement my responsibility consists in the development of new processes and or improve existing processed throughout the MEDCOM Business Office. My position included working in an information Technology environment where I design and build solutions that creates and enhances the business flow operations. An experienced Project Manager of five-year’ in planning, implementation and execution and proven ability to support multiple projects with medium to high complexity. Part of my responsibility is to enhancing procedures by creating automotive processes through SharePoint and build programs applications so that the data is visible and accessible to the entire MEDCOM Headquarters. I work with Microsoft project, office, and Visio software; Resource Management policies and practices and change management techniques with an ITIL and Six Sigma Methodology.

Project Manager Consultant/Contractor

Responsible for management of all phases of client service projects in areas of information technology and business systems engineering and refining data solutions

Defined and documented business requirements and business processes with an understanding of data management implementation.

Works closely with cross-function teams and resources to accomplish program goals and milestones within the scheduled time established. Also, managed project closing and ensured project deliverables achieved cost and scope

Developed project plans identifying key dates and resource requirements by gathering and refining the requirement for data management capabilities such as informatics software Enterprise Data Lakes

Assembled and directed project teams of 10 members

Defined and controlled project budgets of up to $250,000

Tracked key milestones, adjusted project plans accordingly and implement project design.

Prepared and delivered reports and recommendations

Worked Federal contracts as Medicare, Medicaid, and Tricare; coordinating projects, systems testing, installation, and support for several health care providers.

Work collaboratively with Information Management Staff, Data Management business analyst staff with a goal of providing identity resolution and enhancing governed data.

Manages risk by establishing project management process (Six Sigma) to address challenges associated with quality, schedule and cost.

Coordinated plan, manage, analyze, and develop activities for projects to accomplish goals and objectives.

Communicate with stakeholders and provide insight on issues through root cause analyses

KGS/ProSphere/Contractor for Veteran Affairs July 2015 to May 2017

7901 Metropolis Drive, Austin, TX 78744

Jon Sampson, Supervisor, 512-***-****

Jerry Lewis, Manager, 512-***-****

SME (Subject Matter Expert) resource for level I, and level II support, creating tickets into the TSM ticketing system, resolve, and document resolution, create and enhance operation policies, and procedural documents and sending to the director of ECD for approval. Provide EFT/EOB/MRA re-post for clients; confirm and reconciliation OGA/CLFMP/DNC claims; conduct a system Health Check for failure and or errors; worked with IT, developers, and other analyst within the ECD to help support implementation, and EDI projects.

Documenting customer service issues, according to the procedure, gathers data and analyze trends/patterns affecting quality by using data mining, SAS, Quantitative and qualitative data research. Possess and eye for detail and an ability to understand current circumstances from the stakeholders; using EDI processes and other tools for testing file development and supporting new and existing business. Maintain new and existing trading partner relationship; perform data analytics for the medical and financial side of the company.

Excellent knowledge of ANSI X12 Standards and HIPAA code lists. Familiarity with XML standards, strong understanding of 834, 835, 837, 810, 850 and 856; WAP, TA1/999, 277CA; integration and provides support to various clients’ on-site and off-site the HIPAA EDI solution for the Healthcare customers for Tricare and Medicare claims with an ITIL v3 Certification, Six Sigma, and CIS Methodology.

Sr. Business/Functional Analyst/EDI HDO

Process the EDI transactions using the Accredited Standards Committee (ASC) X12 standards, the National Council Prescription Drug Programs (NCPDP) standards, and the Health Level 9 (GS9) protocol.

Document customer service issues, according to procedure

PM for special projects/program to resolve challenges associated with the quality and cost of day-to-day business functions.

Understanding health insurance portability and accountability act (HIPAA) compliance policies

Experience with CPT, HCPCS and ICD codes;

Advanced in Microsoft Office

Perform triage and first resolution for production problems and communicating with change requests.

Troubleshooting and resolution, using storyboards modeling

eCommerce pharmacy and financial claims

Analyzed Data, structure trending flow charts, SAP reporting, SAS VirtualBox platform, Visio and Service Desk Manager (DSM) ticketing system management.

Managed Care System (MainFrame)

Serve as a subject matter expert, ensuring visibility to project teams by monitoring and reporting business objects, and project accomplishment

Experience with IBM Rational Concert Configuration and Change Management; IBM Rational Quality Manager and IBM Rational DOORS Next Generation Requirements Management.

Gather data and analyze trends/patterns affecting quality/SQL

Disseminate the work to Team members.

Developing training documentation and demonstration content of enhanced functions for end users

Qualitative and Quantitative data research

Log all Requests for Change (RFC) in Tracking System for Requests, Issues, and Projects application (TRIP).

Maintain VA-FSC EDI Team group mailboxes.

Producing the Weekly Status Report, the Weekly Customer Report, and the Monthly Customer Report

Monitor inbound and outbound email to review response quality, and customer satisfaction

Reports about performance and quality assurance issues for consideration;

Serve as a communication hub for external customers and payers for all incoming RFC.

Distribution of project amongst ECD department

Act as a buffer between the Production Team and smaller production issues quickly resolved by a first level agent.

Research data by accessing various software; Mainframe, UltraEdit, TSM (ticketing system management)

Special projects as requested creating data charts and tables as directed by the CEO and other management teams;

Monthly financial and medical data audits before giving to IT/ECD Chief Operation Executive

Texas Oncology Feb 2015 to Aug 2015

8501 N. Mopac, Suite 310, Austin, TX 78759

Tina Warner, Regional Supervisor, 512-***-****

Patient Account Specialist II, recognized as a team player by taking on special projects as needed to help support the staff and giving a strong knowledge of medical billing.

Patient Account Specialist II

Strong understanding of medical billing and appeals process, experience in monitoring claim rejections, verifying, and obtaining carrier requirements for claims submission; researching payer denials, and resolving filing issues; executing and implementing into Vision Misys, IknowMed, ImageNow, and JP Morgan Systems. Auditing patient files to ensure exact and timely payment to health care provider’s accordance to client plan specifications set for commercial and federal programs.

Reviews aging accounts on a weekly basis finds and resolves problems related to the file and reports inconsistencies; also,

Follow up with insurance companies to ensure prompt receipt of payments and proves the ability to discuss insurance-related issues regarding sensitive financial matters and recapture unpaid balances.

Review EOBs, and COBs, to ensure proper reimbursement

Participate and keeping Payer’s manuals and profiles

Prepares to write off request with proper documentation, insurance, and patient correspondence that includes denials and paid promptly;

Review and research claim submissions to ensure the correct benefit determination as well as the accuracy of payment.

Researchers Medicare reimbursement policies and guidelines for every service type, including DME, and decides Medicare Part C payment disputes with well-supported written decisions.

Assisted in the development of the automated case tracking system

Trained co-workers on how to make and prepare decisions

Communicated with other providers/insurance companies in handling disputes via telephone

Revenue Cycle Billing Sep 2013 to Jan 2015

1817 West Braker Lane, Austin, TX 78759

James Bailey, HR Manager,

Sharon Bell, Manager, 512 658, 0042

Working for Revenue Cycle Billing as an EDI System Administrator at Revenue Cycle Billings, recognized as a problem solver where I suggest solutions that give overall improvement Billing and revenue teams. Part of my response was training junior employees on the PI system and giving level security access; recognized as a team player. I worked the EDI department as a one-man operation for six months successfully. Providing technical support and serve a matter expert and an EDI communicator with strong knowledge of medical and pharmacy billing, medical terminology, HIPAA, and ethical considerations related internal and external customers.

EDI-System Administrator

Experience in monitoring claim rejections, verifying and obtaining carrier requirements for claims submission; Researching payer denials and resolving filing issues; executing and implementing into Tiger Misys and Practice Insight System; testing and auditing to ensure accurate and timely payment to health care providers according to client plan specifications set for commercial and federal programs. Understanding of business functions and ability to understand system interfaces.

Completing and submitting EDI/ERA agreements to clearinghouses and payers;

Ensuring modules processed in the Tiger Misys System; Ensure claims such as EOB’s, electronic data, and appeals

Sort HCFA’s to proper carriers

Print and distribute paperwork daily

Pull weekly reports and closed companies daily

Special projects as needed

Reviewing and correcting rejection claims

Assist VP with month end balancing and closing

Analyze employer group information to identify commercial, government, and self-funded claims

Monitor staff levels to ensure business needs based on the business guidelines.

Strong knowledge of EDI 834, 835 and 837

Experienced in XML and XSD

Understanding of credentialing process; and process payers’ enrollment for EDI submission

Set up new provider in the database and make sure that credentialing paperwork was for Medicare approval.

Provide feedback and ongoing training for staff and management related to job functions

An advanced understanding of medical benefits, for example, HMO, PPO networks, Medicaid and Medicare plans.

Extensive training with Medical terminology, CPT, REV UBE84, and HEFA claim forms

Experience in research, verbal, and written communication; for application inquiries for plans, and staff.

Maintaining changes update and notification required by clients

Understanding of regulation statutory guidelines, HIPAA, and the Affordable Health Care Act

Health Care Scouts Contractor/Superior Health Care Feb 2012 to Sep 2013

2100 S Interstate 35 Suite 202, Austin, TX 78704

Komal Patel, Specialty Pharmacy Manager, 512-***-****

Investigate and audit accounts of suspicious behavior and made a recommendation to take added steps to resolve found false information. During the first six months, my team decreased federal spending by over $600,000 with the department and played as a liaison between the special pharmacy and medical management departments

Specialty Pharmacy Coordinator

Interface directly with Pharmacists through US Script portal or other Health Care professionals, aid Clinical Account Executives, Chip, Foster Care, and staff pharmacists in completing the tactical and operational tasks required to meet the needs our PBM Clinical Department for the federal programs throughout Texas. Collaborate with management, team members. Pharmacy and medical to reject the claims resolution related to complaints and supporting members. Also, formulary changes or medical documentation for the procedure of referral, NDC, or ICD-9 and HCPCS Codes rejections, initiate referrals, prior authorization, and review and process referrals, ensuring that all documentation is received to process a claim efficiently and in a timely manner.

Advanced understanding of health care plans, Chip, Foster Care, Medicaid, and Medicare plans, Medical Terminology, CPT, REV, UBE84, HEFA claim forms, and ICD 9 codes and referral PA processes.

Run application reports through provider information system Amysis and distributed daily workflow.

Assist Pharmacist with utilization review in compliance with health plans, corporate and state policies, and the company’s procedures, and guidelines.

Documented result of decision through CCMS, and Amysis portal

Collaborate with management, team members, and pharmacist’s staff to provide resolution related to issues and concerns; help support members about formulary changes as, NDC, not covered matters, new client implementations, initiating referrals, prior authorization processing to ensure all documentation received to process a claim efficiently.

Review and research claim submissions to ensure the correct benefit determination as well as the accuracy of payment.

Analyze inquiries requesting supporting documentation to conclude the claim payment while verifying accuracy and ensuring timely filing.

Communicate with vendors and providers to obtain additional information to complete reviews, making appropriate claims adjustments when necessary.

Prepare written responses indicating missing information as well as claims denials and actions deemed essential for redetermination.

Assist with resolving difficult issues with both internal and external customers.

Verify coding is appropriate with procedure and according to eligibility requirements

Proactively address rejections as it relates to the clinical and specialty department

Coordinate operational performance guarantees and work clinically-related pharmacy queue for clinical resolution related to retail, specialty pharmacy issues, and member issues

Review and thoroughly investigate denial claim and determine the appropriate course of action for resolution promptly and follow-up denial claims

Create and send approval or denial letters as stated as required

Handle change request to member eligibility, add-ons, and terminations as identified by the client.

Document and identify potential eligibility issues and notified the appropriate party to resolute, customer enrollment in benefits changes.

Matrix Absence Management Feb 2010 to Jan 2012

9390 Research Blvd, Austin, TX 78759

Shamika Wilson, Claims Supervisor, 512-***-****

My time at Matrix Management as a Sr. Integrated Claims Leader. I reduced staff turnover by 15%, benchmarking a record-setting improvement in staff retention; development and morale-building programs and increased customer service satisfaction index from 75% to 98% within six months, and ensured a swift resolution of customer issues for the client and preserving customer loyalty while complying with company policies. Trained, and supervised customer service representatives. I recommended resolution for difficult claim determination, calculate benefits for payroll and process release of checks. Manage short and long-term benefits; worked WC claims when needed, transitioned claims from worker compensation to IEB accounts. Develop and sustain client relationships, investigated eligibility from both a contractual and medical standpoint, coordinated with medical staff, employer personnel, employees, and providers. Complete utilization reviews of cases by guidelines and regulations and document assessment, initiated denial notices via phone and following them up by written documentation and determining the appropriate course of action for resolving claims in a timely manner.

Integrated Claims Examiner

Employees’ Benefits Management, trained audit, and supervise junior staff. I recommended resolution for difficult claim determination, calculate benefits for payroll and process release of checks. Manage short and long-term benefits; WC claims when needed, transitioned claims from worker compensation to IEB accounts. Develop and sustain client relationships, investigate eligibility for contractual and medical necessity, coordinated with medical staff, employer personnel, and providers. Completed utilization reviews of cases by guidelines and regulations. Thoroughly review obtained medical documentation, making sure that all prior authorization is in place. Send denials letter via USPS and phone and determine the appropriate course of action for resolving the claim in a timely manner. Document call in letters received from patient and utilization reviews to the company system.

Assist in training and supervised lower level employees

Cost control

Complete utilization reviews of cases by guidelines and regulations and document assessment

Close interaction with employee, client, and physicians and assist with job coach in making recommendations for returning workers back to work full duty or no less than r/L's

Provide direct oversight of claims processing activities in meeting production, deadlines, and quality standards.

Communicate with other departments to enhance employee return to work speedily

Document correspondence and determination of review according to SOP and State requirements

Implement approval and denial documentation for employee and record system for clients as required

Quality control and improvement

Initial assessment of the denials via phone and determine the appropriate course of action for resolving rejected claims in a timely manner

Collaborate with other departments with turning around the underperforming area. Train CSRs significant improvements for client satisfaction and productivity.

Respond to correspondence and inquiries within turnaround time of 24 hours after request

Medical necessary decision-making using some local and national coverage determination guidelines for BME and inpatient, outpatient clinics and extremely complicated or unusual claims

Reviewed new and audited existing requests for determination of benefit eligibility and meeting policy processing deadlines

Boon-Chapman Jul 2008 to Jan 2010

9401 Amberglen Blvd Bldg. I, Ste 100 Austin, TX 78759

Gerald Lewis, Manager, 512-***-****

Healthcare Benefits Lead Analyst, served as the go-to person to analyze payer contracts, provider’s manual and other sources of payment guidelines to prepare contractual fee schedules and produced the highest excellence in customer service six quarters during 2008 and 2010.

Senior Claims Benefits Analyst

Front-line lead analyst building, executing, and implementing the COS and Eldorado system, testing, and audited medical claims to ensure accurate and timely payment to health care provider’s accordance to client’s plan specifications, including commercial and federal plans; generated COBs, EOBs, approved, and denied letters pertinent to determining results. Promptly identified under or overpayment errors, and assisted with the audit improvement processed as needed. Resolving claim rejections related to billing codes before sending to the insurance company, ensuring that the right provider and credentialing are valid, and accordance with company guidelines.

Supervised, trained, and supported quality work ethics

Analyze accuracy of ICD-9 and HCPCS Codes used to send claims for payment for the reimbursement on the explanation of benefits (EOB) and coordination of benefits (COB)

Verified for correct codes and bundling rules used for claims and payments reimbursed by billing and coding guidelines

Understanding of the complete healthcare revenue

ICD-9 and new plan implementation; interface with clients to understand their needs and configuring software to meet those needs; running usability of testing for readiness, and create a procedural manual based on the need of the client

Audit medical billing claims via manual from US mail or electronically using payment data forms and practice management systems;

Manufacturing processes and procedures

Resolved rejected claims

Analyze employer group information to identify commercial, government, and self-funded claims

Complete understanding of medical and pharmacy benefits as, HMO, PPO networks, Medicaid, and Medicare plans.

Extensive training with Medical terminology, CPT, REV UBE84, and HEFA claim forms

Extensive experience and research, verbal, and written communication, for application inquiries for plans and staff

Understanding of regulation statutory guidelines, HIPAA, and the Affordable Health Care Act

Walgreens Health Initiative Oct 2003 to July 2008

7357 Greenbriar Pkwy Orlando, FL 32819

As a Healthcare Benefits Leader, the staff nominated me as employee of the month for two months straight for an important leadership building and exceeded customer service benchmarks. As part of the management team, I handled training, monitoring, and auditing junior staff member’s job performance. Moving up the ladder very quickly, I was appointed as a Project Manager for Walgreens Health Initiative to jump-start a new Medicare part D concept in Oklahoma, ensuring the work projected aligned with the company objectives, while successfully managing customers’ Benefit's need and staff expectations.

Provider Relation Resolution Supervisor

Five years functioning in a leadership role for provider resolution, claim management and served as a liaison between the Medical Management Department, and Pharmacy Department, which includes Retail and Specialty Pharmacy, Reimbursement, Billing Department, and Clients Relations Department. To effectively identify and resolve claim issues. Collaborate with others on the Provider Relations team to address reimbursement challenges and concerns regarding provider contracts. Overseen junior representative; provide instruction to the compensation team regarding updated policies and procedures to assure prompt and accurate claim adjudication.

Supervised daily workflow of the provider relations functions in compliance with health plans, state policies, procedures, and company guidelines

Work as a release person as needed in the absence of Senior Benefits Management

Collaborate with corporate to obtain a manual check based on reimbursement per client plan

Document provider interaction monitored the Provider Relation queue by e-gain web and respond with 24 hours of notification.

Coordinate and participate in meeting with providers to conduct orientation, educating providers on claim policies and procedures, delivering written material, or contracting with our health plan's network.

Understanding of the complete healthcare revenue cycle

Run application reports through the provider information system,

Handle change request for member eligibility, add-ons and terminations of plans as identified by the client

Documented and identified potential eligibility issues and notified the appropriate party when resolved regarding customer enrollment and benefits changes

Worked as a Senior Specialty Pharmacy Coordinator providing medical information and implementing data into a drug safety database

Maintain patient profile to keep current as possible

Worked as a Reimbursement Senior Specialist Lead spotting and investigating the details in insurance claims that may indicate insurance coverage abuse, fraud, and unwarranted medical procedures.

Identify, research, and review problems related to overpaid or unpaid claims

Reviewed rejected or returned claims and resolved issues related the claims promptly.

Answered queue inquiries, from medical, pharmacy and customers regarding coverage and explaining rejection related to experimental treatment or controversial procedure.

Communicated with different department of account billing operation to resolve issues

Run reports exporting data to produce audits and cost estimates

Also, worked as Customer Service Representative Lead handling difficult customer calls and complaints, correspondence related to insurance coverage or policy, including eligibility updates as a client request, in additional training and supervising junior representatives

Education:

Grand Canyon University, Doctor of Education Organization Leadership/Health Care Administration Ed.D.

Strayer University, Masters’ Business Administration/Information System Management, MISM

Strayer University, Bachelors’ Business Administration/Health Service Administration, BSHA

Florida Metropolitan University, Associate Degree in Business Administration/Finance, AA

Ivy Tech Community College, South Bend IN. Practical Nursing, PN

Ross Medical, Saginaw, MI Medical Assistant, MA

Skills and Certification:

Result driven and able to find ways to resolve problems and have an ITIL v3 and Six Sigma Methodology

Ability to lead and develop a department and plan overall program and monitoring the progress

Support Business Operations by defining goals and requirements related to issues

Developing

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