Customer Service Advocate
Resume:
Angela L. Robinson
Myrtle Beach, South Carolina 29588
OBJECTIVE: To maintain a position that offers challenge and growth with a stable company, where my abilities may be utilized.
EXPERIENCE:
PGBA (Blue Cross Blue Shield of SC) Surfside Beach SC
Claims Supervisor-TRICARE April 2022-Current
Reviews claims or appeals issues, complaints, and inquiries referred by claims customer service representatives to determine if desk procedures and guidelines were followed. Researches to identifying underlying causes, and determine ways to prevent and correct such causes. Identifies and reports potential fraud and abuse situations.
Researches and responds to complex customer inquiries, ensuring that contract standards and objectives for timeliness, productivity and quality are met. Handles situations that require adaptation of response or extensive research.
Examines and processes claims and/or non-medical appeals according to business/contract regulations, internal standards and examining guidelines. Enters claims into the claim system after verification of correct coding of procedures and diagnosis codes. Ensures claims are processing according to established quality and production standards.
Provide feedback to management regarding customer issues. Maintain accurate records concerning issues. Follow through on complaints until resolved or report to management as needed.
Maintain knowledge of procedures and policies. Assist with process improvements by recommending improvements in procedures and policies. Assists in training claims customer service representatives.
PGBA (Blue Cross Blue Shield of SC) Surfside Beach SC
Customer Service Advocate II-TRICARE November 2017- April 2022
Responded to provider and beneficiary telephone inquiries in a courteous manner.
Worked and reviewed correspondence inquiries to ensure quality and timeliness.
Performed research as needed to resolve inquiries.
Keyed and processed provider and beneficiary claims.
Worked claim deferrals as outlined by TRICARE policies and procedures.
Trained new hires.
Assisted with the Veterans Alliance Program (VA) by working correspondence based on their procedures and timeliness.
PGBA (Blue Cross Blue Shield of SC) Surfside Beach SC
Customer Service Advocate II –Federal Bureau of Prisons and North Carolina Department of Public Safety (FBOP and NCDPS) September 2016- November 2017
Responded to calls from prison facilities regarding claim processing and status.
Processed and keyed facility claims according to company guidelines and facility direction.
Skilled in Microsoft Word, Excel, Powerpoint and Access.
Priced claims in various Medicaid and Medicare pricing methodology.
Proficient in complex and manual pricing of Medicaid and Medicare.
Coded and drafted estimates for service authorizations.
PGBA (Blue Cross Blue Shield of SC) Surfside Beach SC
Customer Service Advocate II-TRICARE March 2011- September 2016
Responded to provider and beneficiary telephone inquiries in a courteous manner.
Worked and reviewed correspondence inquiries to ensure quality and timeliness.
Performed research as needed to resolve inquiries.
Keyed and processed provider and beneficiary claims.
Worked claim deferrals as outlined by TRICARE policies and procedures.
Palmetto GBA (Blue Cross and Blue Shield of SC) Columbia SC
Provider Relations Research Specialist December 2007-March 2011
Responded to complex referrals from the Provider Contact Center (PCC). Researched and responded to Congressional inquiries. Processed requests for the Department of Justice. Assisted Provider Education, Medical Review, and other internal customers including the Centers for Medicare and Medicaid Services (CMS) with complex inquiries. Provided clear and accurate written responses in accordance with Palmetto GBA, CMS requirements.
Facilitated and actively participated in the development and maintenance of provider educational reference materials to include manuals.
Performed analysis of provider contact data to identify billing trends and facilitated the development of educational materials in conjunction with the PCC manager, Medical Review and other departments.
Developed and delivered weekly training to the PCC.
Gathered monthly information for monthly reports to management.
Assisted the PCC with answering high call volumes.
Assisted with special projects and reports as requested by management and other various departments.
Palmetto GBA (Blue Cross and Blue Shield of SC) Columbia SC
Medicare Service Representative II July 2007-December 2007
Ensured effective public relations by responding accurately and timely to telephone, written and walk-in inquiries from customers.
Initiated re-openings or other research as needed to resolve customer inquires
Responded and/or assisted with priority inquiries, special projects and system testing as required by management.
Reviewed written correspondence to ensure accuracy and quality guidelines were met.
Palmetto GBA (Blue Cross and Blue Shield of SC) Columbia SC
Medicare Service Representative I July 2004- July 2007
Maintained all departmental productivity, quality and timeliness standards.
Coordinated with other departments such as medical review and professional reimbursement to resolve problems.
Assisted with special projects and system testing as required by management.
Responded to provider telephone inquiries.
Worked and reviewed correspondence inquiries to ensure quality and timeliness.
Eagle Aviation West Columbia, SC
Receptionist May 2003-August 2009
Typed, edited, formatted, reviewed, and updated numerous forms, correspondence, documents, chart/graphs and reports.
Maintained full coverage of telephones, recorded minutes of meetings, and made travel arrangements/ reservations.
Angela L. Robinson Page 2
Palmetto GBA (BlueCross BlueShield of SC) Tricare for Life Columbia, SC
Claims Associate III March 2003-July 2004
Researched and responded to routine telephone inquiries according to desk procedures.
Provided inquires to all correspondence from providers and customers.
Processed and adjusted claims according to department guidelines.
Worked specialty deferrals such as third party deferrals.
APAC Teleservices, Inc. Columbia, SC
Scheduler (TCS) October 1999-April 2001
Maintained employee records and scheduled new hire classes in TCS.
Assigned ACD logins.
Updated historical call volume, hierarchy, and force models.
Reviewed time off requests.
Processed error reports and payroll files.
Reviewed schedule changes.
APAC Teleservices, Inc. Columbia, SC
Quality Analyst July 1997- October 1999
Monitored customer service representatives to ensure quality customer service provided on all telephone calls.
Processed daily reports reflecting status of monitored calls.
Trained on quality measures and guidelines.
EDUCATION: August 1991-June 1993 Newberry College
Major: Biology
SKILLS:
TCS, IEX, ATS scheduling software
Microsoft Office Programs
Switchboard Operator
Palmetto GBA Change Management Database
AWARDS AND RECOGNITION:
Golden Telephone Award (Palmetto GBA)
Employee of the Month (Palmetto GBA)
PRRS/ POE Team of the Year (Palmetto GBA)
REFERENCES: Available upon request.
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