Customer Service Medical Claims

Michelle Gilmore-Smith

Hampton, GA ***** Cell: 770-***-**** Email: **********@*****.***

SUMMARY OF QUALIFICATIONS: Medical Claims Specialist with 15+ years of experience providing quality customer service and medical claims support to brokers, providers, group administrators, and sales associates.

PROFESSIONAL EXPERIENCE

Grievance/Appeals Analyst I Anthem Blue Cross Blue Shield, Richmond, VA 2017 to 2022

Reviews, analyzes and processes non-complex pre service and post service grievances and appeals requests from members for multiple products (i.e. HMO, POS, PPO, EPO, CDHP, and indemnity) related to clinical and non-clinical services, quality of service, and quality of care issues

Reviews, analyzes and processes non-complex grievances and appeals in accordance with external accreditation and regulatory requirements, internal policies and claims events requiring adaptation of written response in clear, understandable language

Utilizes guidelines and review tools to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize and route to nursing and/or medical staff for review

Analyzes and renders determinations on assigned non-complex grievance and appeal issues and completion of the respective written communication to convey the determination

Senior Claims Representative Anthem Blue Cross Blue Shield, Richmond, VA 2016 to 2017

Keyed, processed, and adjusted medical claims in accordance with claims policies and procedures

Adjusted voids and reopened claims on-line within guidelines to ensure proper adjudication

Participated in special claims workflow projects, including projects involving legal matters

Responded to telephone and written inquiries and initiated steps to assist callers regarding issues related to the content or interpretation of benefits, policies and procedures, provider contracts, and adjudication of claims

Responsible for the discovery, validation, recovery, and adjustments of claims overpayments

Audited paid claims for overpayments using various techniques including systems-based queries, specialized reporting, or other research

Responsible for coordination of benefits, Medicare, and medical policies

Worked closely with staff from other departments on a regular basis to ensure customer satisfaction

Performed collection activities to ensure the recovery of overpayments

Customer Service Representative Anthem Blue Cross Blue Shield, Richmond, VA 2005 to 2015

Provided customer service to plan administrators, sales associates, and brokers by answering benefit questions, resolving issues and educating callers on Affordable Care Act and traditional health plans

Determined eligibility and applied contract language for each case assigned

Maintained enrollment database; verified enrollment status, processed changes to records, researched and resolved enrollment system rejections

Maintained and reconciled premium bill, self-bill and individual-billed accounts

Notified clients of premium discrepancies through payment adjustment notices and detailed audits

Developed and maintained positive customer relations by coordinating with various functions within Anthem, including the Claims and Member Services groups, to ensure customer requests and questions were handled appropriately and in a timely manner

Handled inquiries related to enrollment, eligibility, contract benefits, and claims issues

Documented inquiry outcomes for accurate tracking and analysis in CCB

Quoted eligibility and benefits to providers

Processed payments for Member Services for Affordable Care Act policies

Interpreted claims to determine primary or secondary liability

Assisted with ad hoc special projects, including decreasing major inventory for the West Local Offshore group

Led Q&A chat for Provider Services

Trained new hires

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