Customer Service North Carolina

MILLICENT ALEXANDER, CPC

Phone: 919-***-****

Address: Charlotte, North Carolina

email: *******************@*****.***

PROFESSIONAL SUMMARY

Dedicated and motivated professional with 20+ years of health insurance industry experience. Strong background in leadership and training. Proven leadership and collaboration skills strong problem solver with excellent analytical research skill.

SKILL HIGHLIGHTS

Staff Development/Employee Engagement. Leadership

Conflict Management Time Management

Microsoft Excel, Word, Power Point Customer Service

Certified Professional Coder Training and Development

PROFESSIONALL EXPERIENCE

Inter-Plan Program Specialist July 2022- Present

Blue Cross Blue Shield, Durham NC

Work as a liaison between BCBSNC and all BCBS Partner Plans, Provider Representatives, and other BCBSNC departments serving as an operations expert to provide dedicated service and end to end issue resolution within the Inter-Plan Program (IPP) requirements.

Responsible for the accurate resolution of Medical Record and Appeal Request/Responses

Provides feedback of trends, risks and impacts; proposing solutions and ensuring all obstacles are eliminated for proper and timely resolution; communicating results or proposed solutions to the appropriate stakeholders.

Partner with other BCBSNC departments to ensure education of BCBSA guidelines and Scorecard impacts/metrics.

Serve as a Subject matter expert on Inter-Plan business across all lines of business, identify gaps or inconsistencies in workflows, and/or processes; recommend updates, alternatives and/or solutions.

Serve as a point of contact representing department in meetings, handle special projects as necessary and provide training when needed.

Responsible for user acceptance testing: verification of results, escalation and reporting of findings and approval of results.

Appeals and Grievance Specialist November 2021- March 2022

LA Care Health Plan, Los Angeles CA

Analyze and resolved verbal and written claims and authorization grievance/appeals from members

Resolve all State inquires related to complaints, grievances and appeals

Review and process member grievances within federal, state and organizational regulations and policies and procedures

Review claim grievance for reconsideration and either approve/deny based on determination level

Review and determine if claim grievance includes a potential quality or access issue

Collaborate with subject matter experts within the organization to obtain benefit and/or clinical opinions/interpretations of complex cases

Correspond with key individuals regarding grievance and appeal decisions

Act as subject matter expert regarding grievances and appeals

Manager, Grievance & Appeals November 2019- August 2021

Carolina Complete Health, Charlotte NC

Creation of workflow/ process, and procedures based on State requirements.

Ensure appropriate processing of member grievance appeals, provider appeals, or request for a State Fair Hearing.

Perform duties as the point of contact with the State.

Manage the day-to-day responsibilities of the Grievance & Appeals Coordinators.

Work with other functional areas and provide training on the Member /Provider Grievance and Appeals process.

Ensure that the Grievance and Appeals department processes all appeals and grievances in accordance with referred time frames and other contractual legal requirements.

Monitor appeals and grievances and provide senior management with monthly reporting for tracking and trending.

Ensure that all members and provider grievances are processed and investigated according to contract requirements.

Work with various external constituencies, i.e., state, local and federal governments, local community and the public related to grievance and appeals.

Integrate federal and state law changes into company’s regulatory system related to grievance and appeals.

Recommend solutions and works with department and company staff to ensure problems are corrected and departments are advised of corrective measures to prevent recurrences.

Provide requirements to external vendors in developing procedures to comply with grievance and appeals requirements.

Resume review and interview prospective new hires for Grievance and Appeals staff as well as other functional areas within the Quality Improvement Department.

Appeal Senior Department Instructor 2016–2019

Blue Cross Blue Shield, Durham NC

Conduct 8-week training sessions for Member/Provider Grievances and Appeal including Provider Coding reviews with new employees, using various training methods to engage employees, including hands-on, interactive activities and audits.

Coordinate and conduct small group and individual training sessions based on department needs.

Continuous improvement of training programs, including ongoing learning opportunities related to Grievance and Appeals process and system updates.

Performed department audits

Evaluate existing training materials, determining what changes need to be made to keep these materials relevant and updated with department policies and procedures.

Trained Grievance and Appeals staff on updated policy and procedures.

Resume review and interview prospective new hire staff when needed

Appeals Team Lead 2008–2016

Blue Cross Blue Shield, Durham NC

Oversee daily operations and case-load assignments and priorities.

Supervise the formal process to ensure the resolution of all Member/Provider Grievances and Appeals.

Coordinates work assignments between teams

Direct staff for Member, Provider and Coding appeals as well as Utilization Management, Claims and Quality issue determinations.

Take action, make decisions, and shape team or group priorities to reflect the organization’s core competencies.

Identifies and resolves operational problems using defined processes, expertise and judgment.

Resume review and conduct interviews for prospective new hire staff.

Ensure that all Member/Provider Grievances and Appeal are processed and investigated according to contract requirements.

Ensure Member/Provider Grievances and Appeal decisions are guided based on policies, procedure, appropriate medical policy as well as coding guidelines.

Gather, analyze and report written member and provider complaints, grievances and appeals

Appeals Analyst I 2004-2008

Blue Cross Blue Shield, Durham NC

Responsible for responding to written grievances and requests for appeals that involve complex matters for Commercial and Medicare line of business when applicable.

Responsible for performing comprehensive research to clarify facts and circumstances.

Able to identify the root cause for an issue.

Assure that customers and health plan members and providers receive exceptional service when acknowledging, discussing, documenting, or responding to their issue of dissatisfaction.

Makes initial decision regarding resolution of complaints, grievances or appeals based on completed research.

Act as a member advocate in each case, comparing the grievant/appellants issues with the organization s documented facts.

Analyze and resolve written claims and authorization appeals from providers and members.

Purse resolution of formal grievances from members.

Prepare response letters for member and provider complaints and grievances

Maintain files on individual appeals and grievances.

Manage large volumes of documents including copying, faxing, and scanning incoming mail.

Researched and resolved expedited Member and Provider issues.

Trained Appeals Analyst staff on new policy and procedures.

Point of contact with American Imaging Management for Appeal issues.

Responsible for training staff on Diagnostic Imaging Management procedures.

Certifications

Certified Professional Coder (CPC) – May 2007

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