Customer Service Management

SHARON BILL

** *********** ****** ****, ******, NJ 08820

Home: 908-***-**** - Cell: 908-***-**** - ************@*****.*** PROFESSIONAL SUMMARY

Highly analytical healthcare management professional combining more than 20 years of work in long term care with proficiency in financial management, leadership and positive clinical outcomes. Innovative, customer-oriented healthcare administrator with background in managed, ambulatory and long-term care. Strong background in quality assurance, claims analysis and management principles and practices. Seeking a leadership role within an integrated delivery system.

SKILLS

Strong presentation skills

Effective staff coach

Planning and development

Analytical thinker

Supervisory training

Knowledge of Medicaid statutes and

regulations

Quality improvement competency

Independent judgment and decision

making

Promotes positive behavior

Quality improvement competency

Effective staff coach

Independent judgment and decision

making

WORK HISTORY

09/2014 to 08/2015Capabilities Analyst

Horizon Healthcare Innovations – Newark, NJ

Collaborated with a small team to design and Implement a Care Plan Management. system.

Documented business requirements for enhancements to medical Management systems

Troubleshooted and resolved web applications issues escalated from customer support and other departments with 100% success rate Worked with clients to analyze computing and network needs and installed appropriate solutions within each organization budget Documented work-flows and participated in user training sessions

Created test scenarios and UAT documentation

Created requirements aligned with new PCMH ACO, EOC models. 09/2007 to 09/2014Trainer ll

Horizon Blue Cross & Blue Shield of New Jersey – Newark, NJ Responsible for the facilitation of product knowledge, customer service, claim processing systems, coding ie (CPT 4, ICD-9, ICD-10, HCPC codes), and Hippa laws

& Affordable Care Act.

Coordinated and delivered training for internal employees, new hires and vendor contracts for both National and International contracts. Conducted Gap Analysis to identify and recommend appropriate learning situations in alignment with business partner requirements.

Developed formative and summative evaluations, including, skill and knowledge based assessments, pre and post training surveys and error trend analysis to accurately assess and measure training effectiveness. Conducted interactive member experience problem-solving and escalation workshops for the entire Service Division o provide extraordinary service to plan members. Utilized scenario-based role plays and exercises to implement and reinforce behavior and performance in compliance with customer service standards.Supported administrative reporting of training metrics and provided recommendations for process improvement.

Delivered training for process of claim adjudication on Nasco claims processing system.

06/2005 to 09/2007Utilization Management Representitive Horizon Blue Crss & Blue Shield of New Jrsey – Newark, NJ Prepared appeal cases for review by Medical Director Obtained member, information along with claim number, date of service, claim charges,authorizations and operative report

Meet with Medical director weekly to review the appeal case and determine outcome. If needed, I would adjudicate the claim according to review decision. 03/1999 to 01/2005Senior Provider Service Representitive Horizon Blue Cross & Blue Shield of New Jersey – Newark, NJ Received provider inquires via phone, fax, mail, email ect. Investigate based on the nature of the inquiry (claim number,date of service, member information, unresolved issues in a ticharges

Utilized available resources to quickly and efficiently resolve or redirect inquires in accordance with prescribed department process.

Accurately documented provider inquiries and action taken. Follow up on un resolved issues in a timely manner.

Handle supervisor calls as needed by the team and resolve any issue a network provider had

12/1996 to 09/1999Customer Service Representitive

Horizon Blue Cross & Blue Shield of New Jersey – Newark, NJ Received customer inquires via, phone, fax, mail,email,. if necessary probe for additional information (i.e member ID, claim number, name) in order to effectively handle inquiry.

Review computer claim system and/or other reference material to complete verification process.

Initiated investigation process based on the nature of the inquiry benefits appeals, date of service, enrollment)

Utilize available resources to quickly and efficiently resolve or redirect inquiries in accordance with prescribed departmental process.

Accurately document customer inquires and action taken. Follow up on any unresolved issues in a timely manner, escalating call trends to management, This was a fast paced environment where you were required to take a minimum of 60 calls per day.

Quoted member benefits for all Managed Care products,, Indemnity products. Claims were both medical, prescription, DME and Institutional. If claim adjudication was required all related claims would need to also be corrected. EDUCATION

1985 High School Diploma:

South Plainfield HS - South Plainfield, NJ

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