Customer Service Medical

WANAKEE L. CRUMBLE

*** **** ********* ****, ****** CITY, MO 64114

816-***-**** *********@***.***

Professional Summary

Highly efficient Medical Claims Analyst with experience providing customer support in busy call center

environments for insurance industry employers. Seeking a position to utilize my 25 years of experience

and expertise in the insurance industry, which will also offer challenges and opportunities for

advancement. Answer inquiries from providers regarding claim, eligibility, covered benefits,

authorization status issues

Manage service related follow up items and outstanding tasks in accordance with established turn-

around times

Skill Highlights

Experience providing customer support in busy call center environments for insurance industry

employers.

Complaint Handling/Dispute Resolution

Proficient with medical terminology

Strategic – relationship/partnership-building skills – listen attentively, solve problems creatively, and use

tact and diplomacy to find common ground and achieve win-win outcomes.

Data Entry/Records Management Expert

Professional Experience

Blue Cross Blue Shield of Kansas City Kansas City, Missouri 1995 – Present

Member Services Representative II

Research and identify any processing inaccuracies in claim payments and route to the appropriate

site operations’ team for claim adjustment via FACETS system

Resolve inquires and claim issues resulting in changes to eligibility

Identify and correct problems relating to eligibility, membership and billing

Generate and review member payment notices and delinquency notices

Perform membership duties and resolve multiple-error problems

Handle system timing issues

Review or verify processing of cash adjustments and applications

Determine payment history and resolve inconsistencies

Manage service related follow up items and outstanding tasks in accordance with established

timeframes

Answer inquiries from insured members regarding eligibility, payment status, cancellation and

re-instatement of policies

Installation Coordinator

Interpretation, analysis and coordination of new groups into BlueKC's internal claims processing

system (FACETS)

Timely installation of new clients (groups) while also ensuring a 98% accuracy rate

Received interpret and analyze client requests as provided from the marketing department i.e.

cancellations, additions and/or terminations of products and / or subscribers from the group plans.

Established and activated claims and billing systems for the initial set-up

Accurately updated systems information

Updated and maintained membership eligibility system for all insured subscribers

Dedicated Service Representative/Hallmark Account

Assessed claims information and processed payments for medical expenses according to specific

contract provisions

Researched and resolved problems and discrepancies for the insured party and providers

Performed customer service functions for both internal and external customers

Medical Claims Examiner

Processed cross (hospital) and shield (physician) claims for HMO (health maintenance

organization) and PPO preferred provider) accounts

Maintained effective communication with internal and external customers

Kansas City, Missouri 1987 – 1994

Business Men’s Assurance (BMA)

Claims Analyst

Examined and processed BMA employee claims

Responded to members and provider inquires by verbal and written correspondence

Determined benefits while applying appropriate ICD-9, CPT and HCPS codes

Education and Training

Bachelor of Science Degree

Medical Records Administration

Avila University, Kansas City, Missouri

Clinical Internship

Research Medical Center Kansas City Missouri

Wyandotte Mental Health Center Kansas City, Kansas

Cardinal Glennon Hospital St. Louis, Missouri

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