Customer Service Team Lead
Resume:
Delores (Delo) Gist
Jacksonville, FL 32247
C: 310-***-****
H: 310-***-****
**************@*****.***
Summary Highlights
Experienced Senior Claim Analyst / Processor with a primary goal of meeting / exceeding productivity expectations with a high level of accuracy. Experienced processing all lines of business (Medicare, Medicaid, EPO, HMO, ASO, PPO and FEP) according to Policies and Procedures, Medical Plan Benefits, Limitations and Exclusions. I ensure accuracy by researching / applying authorizations when required, resolving all System Claim Warnings and Errors Messages per job aids / Ollie Docs etc. to resolve /Pends and release the claim to full adjudication / Paid status or Pend the claim to the appropriate dept for updating COB, correcting eligibility issues / discrepancies such as incorrect sex, age, etc, submit Service Forms for Benefit Config issues, add appropriate Claim Notes to explain special pricing, number of units used for benefits with limitations, special exceptions while maintaining a high level of accuracy and meeting time sensitive deadlines to avoid Interest / Penalties. Resolve all Pend items within 24 hours and not exceed 72 hours for my claim full adjudication / finalization.
Experienced Auditor and Senior Claim Analyst / Processor / Senior Team Lead with a successful track record of fully evaluating information, structures and procedures and initiating corrective actions. Committed to improving business compliance, workflow and processes through detailed audits and improvement recommendations. Provided daily Peer Audits for my team.
December 2005 to Present Jacobson Solutions Chicago, IL Project Team Manager / Project Team Lead /Project Claim Analyst Trainer/ Insurance Customer Service Representative / Claims Analyst/Processor / Enrollment Specialist / Claim Auditor / Manual Claim Processing. Independent Contractor Worked with several systems for researching to finalizing ICD-9 & ICD-10, Rev Codes and CPT coding issues, Manual Pricing, identifying Provider configuration issues, Prior Authorization Issues (Ollie Docs – Manual Claim Pricing and SOP Claim Analyzing/Processing experience) with a high level of accuracy in a timely manner, perform special project audits and reviews, keep management apprised of issues that may arise, train new staff, communicate training issues to management as identified through audits and adjustments, provide accuracy feedback / instructive and constructive feedback to Claim Analysts, report audit results and error trends to management, timely results, come to independent conclusions that can be interpreted clearly and sustained through data without significant guidance.
Worked with several systems to research and resolve ICD-9 and CPT coding matters, manual claims processing per Ollie docs or SOP and Prior Authorizations including Call Care Browser, Facets4, Luminex, Coreport, FEP Direct, Insinq, Main Frame/Oscar, Core Port, Air1, CMBS, WGS/Mainframe, ITS, NetworX Pricer, ENT, Ultera, GP00, People Soft, Data Base, Check Inquiry, Lotus Notes. VPN, E-Pact, CSS, TPX, Edsnet, Image Retriever, Pinnacle, VAT, Clipboard, MS Word, Client Manager, Outlook, Benefit Changes, Eldorado, Alieci, Access, QNXT, NAP, Cadence, Nice, Lotus Notes, CSIR Repository, Common Archival Retrieval System, ABC Foundation System / KPTPX, HP Chats, ICS & Customer Interface, CAS, AS400, Epitome, EXP MACESS, Power MHS, Teams, Tableau 2023, 3M Core Grouping Software 2023, Pricing Toolkit, Aspect Telephone System, and basic office equipment.
Performed duties with Anthem's Correspondence team. This includes calling back providers and members to ensure that their request has been properly handled. Facilitated training with new employees, providing quality assurance.
Blue Cross Experience
DATES
COMPANY
JOB DESCRIPTION
SYSTEM
12/2005 – 5/2006
BCBS Wellpoint
Woodland Hills, CA
Provider & Member
Customer Service &
Medicare Claims
Adjustment
Call Care Browser &
Mainframe/WGS
05/2006 – 10/2007
Anthem BCBS
Indianapolis, IN
Provider & Member
Customer Service; Member Billing; Correspondence; Claims Rework / Adjustment; Home and ITS Host Plan / Blue Card Claim Processing.
Facets 4 Series, Ultera, GP00,
People Soft, Data Base, Check
Inquiry, Lotus Notes
01/2008 – 04/2008
BC of PA
Wilkes-Barres, PA
FEP Direct Provider and
Member Customer Service,
Medicare and Non-Group
Member Customer Service
; Pre Sales
Oscar/ Mainframe, InSinq, Core
Port, Air1, Aspect Telephone
System
05/2008 – 02/20/2009
Anthem BCBS
Worthington, OH /
WAH
Host / Non-Host Blue Card
Medical Claims Processing
/ Adjustments & Pricing, COB Processing .
WAH
WGS / MainFrame, NetworX
Pricer, ENT, Ultera, GP00, VPN
, E-Pact
08/17/2009 –
10/09/2009
BCBSAZ / Phoenix,
AZ
Team Lead & Customer
Service
Individual Members
Billing, Benefit Changes,
Rate Increase – explaining.
plan benefits and options to
lower premiums.
CSS, TPX, Edsnet, Image
Retriever, Pinnacle, VAT,
Clipboard, MS Word, Client
Manager, Outlook, Benefit
Changes, and Aspect Telephone
System.
6/2012 – 2/2013
BCBS / Portland, Oregon
Host / Non-Host Blue Card
Medical Claims Processing
/ Adjustments & Pricing.
WAH
Facets, Image
Retriever, Clipboard, MS Word, Outlook,
08/2014 – 06/2015 & 08/2015 - 12/2015
BCBSAZ / Phoenix,
AZ
Team Lead & Enrollment Specialist
CSS, TPX, Edsnet, Image
Retriever, Pinnacle, VAT,
Clipboard, MS Word, Client
Manager, Outlook, Benefit
Changes, and Aspect Telephone
System
12/14/2020 – 2/2022
BCBSKC / Kansas City, Kansas
Team Lead & HMO / PPO Claim Processing, Host / Non-Host Blue Card
Medical Claims Processing
/ Adjustments & Pricing, COB Processing. Medicare claim processing and COB
WAH
Facets, Image
Retriever, Ollie Docs, Clipboard, MS Word, Outlook,
4/22/2022 – 9/25/2023
Healthfirst
Team Lead & Medicaid / Medicare medical claims processing/ Adjustments, R & R, Frontend and Backend claims processing including COB, resolve all authorization, eligibility, claims warning and error edits, data entry errors, and pends with maintaining high level of accuracy. Team Lead - Attending weekly Team Lead meetings, weekly meetings with the Project Manager and client, report my team production, attendance, while supporting my team with daily Peer Audits, provide a resolution for difficult claims within 24 - 72 hours, provide additional team trainings as required, share individual team member stats and provide Employee Performance Improvement Plan if necessary to ensure our success of meeting and exceeding the client’s expectations / standards.
Citrix Workspace, EXP MACESS, Power MHS, Teams, Tableau 2023, 3M Core Grouping Software 2023, Pricing Toolkit, Excel, Outlook, Pega / PSRUserPortal, TruCare, Evicore, Claims Knowledge Center, Job Aids, NPI Utility Lookup,
Education
FCCJ Jacksonville, FL, USA Health Information Management
1.5 Years of College
Florida Licensed Realtor
References
Ashley Shanks, Recruitment and Selection Analyst
Cook County Health and Hospital System
******.******@****************.***
Melina Konstantinidis, Finance Rep
TPC The Payroll Company
**********@*****.***
Darlene Kramer, Project Manager
Jacobson Solutions
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