Keshia Danell James

Columbia, SC ***** US

Skills

Billing & Coding

Medicare Advantage

Cerner

Payment posting

Medicaid

Customer & Client Service

Office Management

Data Analysis

CMS Guidelines & Practices

Epic

Microsoft Office Suite (Word, Excel, Outlook, PowerPoint, Teams), Workday, Salesforce

Education

High school Diploma, Loris High School, Loris, SC

Diploma Medical Billing and Coding, Ultimate Medical Academy, Tampa, Fl

Professional experience

Banner health- Phoenix, AZ 03/2023-9/2023

Grievance and Appeals Coordinator

Analyse, investigate and resolve appeals, complaints, and grievances associate to claim events to establish what the company’s liability and entitlement will be.

Blue Cross Blue Shield - Columbia, SC 01/2023-3/2023

Claims Customer Service Advocate

Provide prompt, accurate, thorough, and courteous responses to all complex inquiries from Medicare Advantage members and providers.

Perform research as needed to resolve inquiries.

Review claims or appeals issues, complaints, and inquiries referred by Member Service Reps.

Maintain accurate records concerning issues.

Follow through on complaints until resolved or report to management as needed.

Sends out benefit enrollment packets to all newly eligible members.

Blue Cross Blue Shield - Columbia, SC 09/2022-12/2022

Senior Client Service Representative

Provide prompt, accurate, thorough, and courteous responses to all complex inquiries from Medicare Advantage members and providers.

Perform research as needed to resolve inquiries.

Review claims or appeal.

ls issues, complaints, and inquiries referred by Member Service Reps.

Maintain accurate records concerning issues.

Follow through on complaints until resolved or report to management as needed.

Sends out benefit enrollment packets to all newly eligible members.

Order ID cards, Track and process all new member benefit enrolments.

Highmark Health, Columbia, SC 01/2022-9/2022

Claims Customer Service Advocate

Review patient records and policy requirements.

Process and adjust claims meeting daily productivity.

Maintain daily and direct communication.

Work professionally and with due diligence and be expeditious to meet quality and production requirements.

Maintain the highest standard of customer service including professionalism, courtesy, patience, and respect.

Blue Cross Blue Shield -Columbia, SC 09/2019-01/2022

Claims Processor II

Review patient records and policy requirements.

Process and adjust claims meeting daily productive/verify enrollment and benefits.

Provided prompt, accurate, research thorough professional communication to resolve complex customer inquiries/ issues.

Backend Reports

Price Cooper -Columbia, SC 08/2018-9/2019

Patient Service Representative

Review patient records /claims to identify and correct errors.

Document, access, organized, claims using Epics system and various software.

Communicate with hospital representatives, insurance companies, and internal team members to resolve claims and collect payment effectively and efficiently.

Creating/updating/managing spreadsheets. Process open enrollment benefit plan transfers / Maintain patient benefit files and record keeping.

Blue Cross Blue Shield -, Surfside, SC 06/2014-4/2018

EDI Operations Associate I

Processed EDI claims and patient records to ensure accurate data posted, set-up requests and managed logs and supporting documents for back up.

Processed and tracked electronic funds transfer for providers. Reviewed daily EDI rejection; research and identified root causes and served as liaison between internal and external teams for appropriate and timely corrections.

Provided prompt, accurate, research thorough professional communication to resolve complex customer inquiries/ issues.

Performed varied clerical office duties, in accordance with standard procedure.

Professionally trained in Records Management.

Prepare reports from different databases utilizing access per request of the internal teams, attorneys, and vendors based on business needs.

Blue Cross Blue Shield - Surfside, SC 07/2013-06/2014

Data Prep Tech I

Performed varied clerical office duties, in accordance with standard procedure.

Professionally trained in Records Management.

Prepare reports from different databases utilizing access per request of the internal teams, attorneys, and vendors based on business needs.

Created reports and analyse data to make recommendations and improvements within department.

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