Customer Service Healthcare

Kristie M. Mack

**** **. ****'s Road • Hillsborough • NC • 27278 •

919-***-**** Mobile • ****************@*****.*** Email

SUMMARY

Twenty-Seven years of Healthcare customer service, of which four years were spent in the Appeals Department and two years as a Credentialing Administrator. I possess knowledge of BCBSNC products, services and systems. I'm familiar with member benefits and claims. I have excellent oral and written communication skills and capable of assisting internal and external customers/stakeholders.

EDUCATION

Winston Salem State University

Bachelors of Arts

Mass Communications Public Relations/Advertising

EXPERIENCE

CREDENTIALING SPECIALIST. MyEyeDr, (Remote)NC 10/13/2023- Present.

•Complies and maintains current and accurate data for all providers.

•Completes provider credentialing and re-credentialing application; monitors applications and follow-up as needed.

•Maintain copies of current state licenses DEA licenses, malpractice insurance and any other required, credentialing documents for all providers.

•Verifies information in NC Tracks/Making sure all payors are paid

•Maintains provider files.

•Maintain knowledge of agency requirements for credentialing providers.

•Monitors provider information in online CAQH database.

•Monitors NPDB/OIG/SAM for any adverse actions or reprimands against any provider.

APPEALS/Grievance RESOLUTIONS Coordinator (Remote) Alliance Health DURHAM, NC 03/01/2020-09/01/23

•Coordinate and assign dispositions of Level 1 Appeals

•Provider courtesy and coding reviews

•Determine appropriate response letter based on disposition.

Assist with internal and external communication.

Read and understand claims history, denials, payments, suspends, and hold codes Serve as the primary point of contact for any incoming correspondence to the Appeals unit.

Credentialing Specialist-Alliance Health 10/2013-03/2020

•Complies and maintains current and accurate data for all providers.

•Completes provider credentialing and re-credentialing application; monitors applications and follow-up as needed.

•Maintain copies of current state licenses DEA licenses, malpractice insurance and any other required, credentialing documents for ail providers.

•Verifies information in NC Tracks

•Maintains provider files.

•Maintain knowledge of agency requirements for credentialing providers.

•Monitors provider information in online CAQH database.

•Monitors NPDB/OIG/SAM for any adverse actions or reprimands against any provider.

Credentialing Specialist/Appeals Coordinator- BCBSNC 12/2008-10/2013

Appeals/Pharmacy Coordinator- BCBS NC 10/2007-12/2008

BENEFIT SPECIALIST BCBSNC DURHAM, NC 10/06-10/07

•Completed Level 1 Grievances and Benefit Exclusions within required time frames.

•Completed special projects when assigned.

•Participated at Benefit Fairs

•All cases loaded in MaxMC correctly to ensure accurate reporting and metrics.

CUSTOMER SERVICE REPRESENTATIVE BCBSNC DURHAM, NC 1/99-10/06

•Initial service contact for BCBSNC customer for all lines of business

•Open, research and close customer and provider inquiries relating to billing, coverage changes and claims.

•Answer all customer and provider questions regarding insurance coverage.

SOFTWARE

• Microsoft Office Suite

• DocRequest

• IPD

• Rightfax

• Mobius

• PowerMhs

• Service First

Smart Sheets

• Echo

Excel

• MaxMC

Smart Sheets

MODIO

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