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Service Representative Customer

Harrisburg, PA
January 06, 2020

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Tashzma Brooks

**** ******* ****, **********, ** 17110 215-***-****

Qualifications Summary

Twenty two years of resolving claim processing and payment inconsistencies via regression / negative & automation testing. Liaison between business and technical groups with expertise in project management, business systems processes and analysis in various defined support role capacities. Liaison between new users within the facility with OSCAR, MHS, EPIC, SMS and NaviCare programs. Developed analytical skills, research abilities and problem solving capabilities.

Professional Experience

Operations Claims Auditor- AmeriHealth Caritas- Operation Quality Auditing - 5/13 to Present

Responsible for the timely and accurate review of various tasks performed by Operations (including, but not limited to, claims processing, call handling and member/provider data maintenance)

Identifies system and/or operational issues hindering the attainment of quality performance standards as defined by AMFC policy and associated business rules.

Provide issue identification, problem analysis and strategies for resolution and/or implementation to upper management

Accurately document audit findings in the appropriate quality tool

Complete claim validation from various business contracts using standards

Work directly with the configuration team resolving claim/system related set-up issues

Audit 360 Monthly MTM (Member Touch Point) Stratified Claims for various Lines of Business

Member Dissatisfaction audits and appeals review

Responsible for auditing High Dollar claims billed over $50,000

Performing claim validation, reviewing agreements and contract updates for Prestige Group

Facilitate weekly meetings to discuss issues with the Prestige SMEs’

Responsible for assigning day to day operations for our Prestige Team

Business Systems Analyst - Independence Blue Cross Systems Development Operations Support 04/05-04/13

Served as Information Services liaison with external vendors, business process owners and management to modify/ design procedures business requirements

Supported system conversions and upgrades

Contributed to the development of implementation plans, deployment and trend metric analysis

Devised Test plans and Business Requirements for business areas during Implementation, working directly with the IS department with resolution of Help Desk Tickets via UAT regression testing and data mining queries and SQL’s results

Handled/audited hold code maintenance on the MHS system while resolving Claim Problem Logs

Developed and tested procedures to support systematic conversions for Software Development (SDLC)

Providing education/training to Analysts for Management on systematic edits and workarounds

Former liaison and point of contact for OSCAR system with departmental instruction/education

Assisted Benefits with the coding of enhancements for prestigious groups

Resolved Claim, Benefit, Enrollment & Provider Problem Logs

Educated and trained customers on claim and system related processes

Received telephone and written inquiries from internal/external customers regarding MHS system problems, edits and enhancements.

Claims Analyst - Independence Blue Cross, OSCAR Support & Systems Development 12/02 - 4/05

Provided OSCAR system security and access to internal/external customers based on the work related necessity and job functionality

Maintained HIPAA compliant log with confidential information for OSCAR systems access for internal/external employees

Received telephone and written inquiries from internal/external customers regarding OSCAR system problems, edits and enhancements

Maintained and resolved OSCAR/Planmate Systems customer feedback logs in an accurate and timely fashion

Team Customer Service Representative / Claims Examiner - Independence Blue Cross - Vanguard Department 9/96 - 4/99

Received telephone and written inquiries from Vanguard associates regarding their Medical, Dental and Vision benefits

Processed upper management HIPPA related claims and analysis

Served as a direct contact for upper management for benefit /claim edit issues

Provided training and support to other team members for resolution of problem logs

Oral and written communications provided to Upper Management

Processed and adjusted claims in an accurate and timely fashion

Systems and Software Skills

Software Tools: Microsoft office (Project, Office, XP, ACCESS, Excel, Word)

Operating Systems - PowerMHS, OSCAR, PLANMATE, SLIQ, FACETS, MACESS, JIVA, CIS, Valutech, GACH, INFO, ICD-9/10 Coding. HCPCS coding and Medical Terminology, SMS, Navicare EPIC, SharePoint, CMS.

Waterfall Framework, Software Development Life Cycle (SDLC). Project/Test Plan Review & Execution


Associates of Science Degree, Piece College, Philadelphia, PA – anticipated 2019

Diploma/Certificate – Network System Administration, SCS Business Technical Institute, Philadelphia, PA

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