Victoria Clairdy

**** *. ****** ***

Peoria AZ **345

480-***-****

QUALIFICATIONS

Expanded years in Customer Service, Medical Billing, and Claims Processing.

Knowledgeable in team interactions and improvement methods/projects.

Extensive knowledge of Appeals and Grievance process and procedures.

Proficient and effective problem solving skills.

Excellent verbal and written communication skills.

Knowledge of Human Resource policies and procedures, FMLA, Medical Accommodations, Workers Comp.

Skills

MS Word, Excel, Outlook, PowerPoint, WGS Mainframe, Lotus Notes, Diamond, Facets,

PeopleSoft, NDB, Workforce Management, Personix, MS Citrix, CareOne, PEGA, Verint.

EXPERIENCE

Mckesson Call Center 01/14/2020-Present

Call Center Supervisor

Manage a team of 10 Inbound call agents taking multiple calls from patients, doctors, and other pharmacies.

I coach and motivate call center representatives as they take calls from applicants.

I hire employees and assist in the training process, ensuring that every agent is well prepared for their calls.

I continue to support agents after training by monitoring their progress, ensuring that they understand and meet expectations, answering their questions, and providing them with ongoing coaching opportunities and inspiration.

My team helps with the refill queue ensuring all calls are completed from patients in a timely manner.

We have weekly huddles discussing any new items the team may need making sure we are answering calls with the most updated information.

We have monthly One on One meetings to ensure each agent is performing to their proposed level; making sure they are aware of their scores with Quality Assurance, and determine what coaching, training, or mentoring needs to be done.

Cognizant Healthcare

Consultant BCBS CA 01/2019-03/2019

Blue Shield/Cognizant Project helped Claims and Provider Services with migration to Facets Platform total 22 associates, helped with understanding the DLP’s, making sure the availability was there to answer questions and pertinent information was inputted into the system. Helping to migrate from the old MHS system to Facets.

Cognizant Healthcare

Claims Team Lead 11/2015-11/2019

Manage a team of twenty-six (26) specialists on two different teams Medical Authorizations, and Regular Medical who adjust Medicaid claims on a daily basis on our production platform Facets making effective decisions for our customer.

Day to day management of all team activities, personnel management, and issue resolution.

Train, develops and organizes the unit staff to use group and individuals to maximize productivity to meet the business objectives. Provides coaching and feedback to staff including interim and year end performance.

Walk the floor to make sure the staff is adhering to the business needs regarding inventory.

Make sure individual staff is put in place to handle inventory that is in the Red not Green to drive down inventory.

Make sure the expectations are met daily from myself and staff to management regarding inventory.

Receive daily reports make sure staff if aware of all inventory and where we may be deficient.

Maintain daily communication with staff regarding inventory and follow up work.

Determine if there are the correct number of staff in the right place within my department to drive down inventory.

Hold weekly meetings to coach, train, and mentor while addressing gaps in performance against internal processes of Quality Audits for education purposes.

United Healthcare M&V 03/2013-09/2015

Referral Operations/Grievance & Appeals Supervisor

Manage a team of twenty-five (25) specialists that include Work at Home, Escalations (Appeals & Grievance), Privacy, INForm, and Referral Processors.

Set-up policy and procedure development, performance metric design, system and testing for operations.

Participate in the interviewing process and procedure.

Represent Referral Management Operations when processing issues arise with the Military and Veterans book of business; participate in conference calls as needed.

Day to day management of all team activities, personnel management, data management/analysis, and issue resolution.

Manage communication processes with multiple levels of staff across our business segment regarding database improvements including conducting research to resolve requests from members, providers, other agencies along with state, and federal agencies.

Hold weekly meetings via WebEx, and in office to coach, train, and mentor while addressing gaps in performance against internal processes of Quality Audits for education purposes.

Coach, Train, Mentor all specialist to address gaps in performance. While Implementing process improvement activities to address areas of non-compliance or ensure procedures are followed while processing all Appeals and Grievance issues.

Enterprise Consulting Solutions, INC 11//2012-03/2013

QUALITY Auditor Processor

Medical chart retrieval obtaining medical records from doctor’s office within the United States.

Responsible for end-to-end retrieval of all medical records through Chart Finder a web-based solution for processing records for individual insurance companies.

Process complete medical records correctly and accurately based on what was entered by the technician.

Responsible for audit reporting to support continuous quality improvement and strict compliance with HIPPA and other healthcare industry standards.

Assist in special projects as needed while assisting management with other audits outside of claims and operations.

Audited 100 cases daily making sure all information was listed, and reported back to management.

Huntington Mortgage Consultant 3/2012-3/2013

Personal Production Assistant (Contractor)

Assisted Eight (8) Loan officers with new applicant refinance and purchases.

Enter applications, pulled and reviewed credit, and evaluated if loan is credit worthy.

Received ALT loan and Disclosure Package documents.

Forward completed and rejected files to appropriate area.

Keyed mortgage claims in Unifi and MSP systems.

Batched all loan disclosures in Unifi and sent to correct loan processor.

Received all new Subordination from Underwriter.

Input borrower information from Passport System Key loan data information from the Unifi system, and forward to manager for approval.

Alliance Data Systems 12/2010-04/2011

Sales & Service Representative

Inbound/Outbound call center environment

Provided excellent customer service

Assisted customers with their individual accounts

Raised or declined credit spending limits

WellPoint BCBS

BlueCard Claims Operations Manager 06/2005-12/2010

Managed day to day activities including compliance with service levels and mandated requirements.

Provided oversight, direction, development, problem resolution, and leadership for the team.

Performance of appropriate delegated vendors and partners on inquiries and complaints.

Serving as the liaison for claims operations for onsite visits by prospective and existing clients.

Interview, hire, train, supervise and evaluate department staff while ensuring department goals are met.

Establish short and long term individual and team goals keeping on track with KPI’s.

Ensures compliance, timely and accurate claims processing with Anthem Blue Cross.

Initiates, coordinates, implements, and completed projects as assigned.

Completed administrative reports based on business needs.

Supported all facets of the day to day operations consulting with various internal and external Blue Plans.

Process medical/hospital claims adjustments for Medicaid and Medicare when need arises.

Day to day management of all team activities including but limited to personnel management, data, management/analysis, and issue resolution.

Implement process improvement activities with my Senior leaders to address areas of non-compliance or ensure procedures are followed while processing all claim.

Hold daily calls, or face to face meetings with the client to ensure timelines and goals are being met.

Wellpoint BCBS 10/1985-5/2005

BlueCard Call Center Supervisor

Inbound/Outbound call center environment

Assisted over sixty (60) associates to make prudent and effective decisions for the customer.

Adjusted claims making sure they were processed and paid in a timely manner.

Handled all irate calls from customers, providers, Department of Insurance and lawyer’s.

Experienced resolving claims issues, scheduling, creating workflows, billing inquires.

Professional collection from customers, and other Insurance companies.

Experience in Medicare, Medicaid, ECRP, DNSP, Escalations for all claims processing.

Training, selects, develops and organizes the unit staff to use group and individuals to maximize productivity to meet the business objectives. Provides coaching and feedback to staff including interim and year end performance.

Provides support to management in the development of business plans and budget.

Monitors performance based on plan and budgets.

EDUCATION

Professional Career Development Institute

Columbus State Community College

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