Customer Service Utilization Management
Resume:
Dawn “Rene” Prater
***** * ***** **. ****** IN **034~Cell 317-***-****
****.******@*******.***
Summary
A result-oriented business professional with 20+ years in the health insurance industry. Articulate leadership skills in dealing with management, peers and staff. Consistently meets or exceeds goals while mentoring peers to improve and maintain quality and production standards.
Skills
Leadership ability
Builds relationships
Problem solving
Microsoft office
Anticipates opportunity
Medical terminology
Drives results
Claims auditing
Provider Enrollment
Customer Service/correspondence auditing
Experience
Anthem Blue Cross and Blue Shield, Indianapolis IN 2024-present
Utilization Management Rep.
Incoming and Outgoing phone calls regarding Utilization Management approvals/denials/case status checks.
Works on faxes received with same information as phone calls.
Receives Utilization requests by chat.
Building cases with Member demographic information, Provider/Facility information, and Clinical information.
Prepare information for timely and accurate submission to Utilization Management area.
Works directly with customer service and Anthem nurses.
Anthem Blue Cross and Blue Shield, Indianapolis IN 2021-2024
Provider Contract Specialist Sr.
Responsible for coordinating the process for more complex pricing arrangements involving high profile provider groups and/or physician groups.
Update provider files.
Prepare information for timely and accurate submission to Provider Data Management area.
Works directly with contracting directors and managers to understand what is negotiated and how the negotiated agreement is translated into the company’s systems resulting in accurate and timely loading.
Anthem Blue Cross and Blue Shield, Indianapolis IN 2012-2021
Performance Quality Auditor III
Central Region Inline Claims Auditor- Federal Employee Program (FEP)
Created and managed monthly audit assignments for Central Region Audit Team. Consist of 1,900+ average audit samples monthly.
Assigned focus audits as needed to auditors on a rotation basis.
Worked closely with training staff, business analysts, process experts, operation experts, and managers.
Facilitated meetings related to audit duties on behalf of manager as needed.
Performed special audits requested from managers and directors.
Worked closely with Process Improvement Director on claims quality forms/reports, and quality workbooks.
Mentored peer auditors and assist with new auditor onboarding. Acted as audit lead for NCQA nite crew letter project with qualifying and impressive results.
Anthem Blue Cross and Blue Shield, Indianapolis IN 2001-2012
Quality Auditor I
Central Region Inline Claims Auditor-Federal Employee Program (FEP)
Created and managed monthly audit assignments for Central Region Audit Team. Consist of 1,900+ average audit samples monthly.
Performed special audits.
Mentored peer auditors and assist with new auditor onboarding.
Anthem Blue Cross and Blue Shield, Indianapolis IN
Claims Processor II 1999-2001
Processed claims in an accurate and timely manner.
Contributed to many group discussions on processing issues.
Received awards for outstanding quality performance. Processed more complex claims.
Anthem Blue Cross and Blue Shield, Indianapolis, IN 1997-1999
Claims Processor
Processed claims in an accurate and timely manner.
Contributed to many group discussions on processing issues. Received awards for outstanding quality performance.
Education Southern New Hampshire University, Hooksett, NH
College for America (CFA)
Completed classes related to Healthcare Management
Ivy Tech State College, Indianapolis IN
Marketing
Obtained 3.5 G.P.A.
Programs/Certificates
Aspiring Leadership Fundamentals Program 2018 graduate
Supported by Anthem
Leadership Enhancement Associate Program 2015 graduate
Supported by Anthem
Contact this candidate