Customer Service Quality Assurance

Cell: 336-***-****

Chanel Williams

Objective

Attentive and detail-oriented with 8+ years of experience in healthcare compliance, auditing, claims review, health insurance appeals, customer service and community outreach. With my previous education, professional and non-profit volunteer experience, I am determined to communicate and produce exceptional work that will contribute to the company’s goal. Striving for excellence will be exemplified in my work which will demonstrate my leadership skills and help to positively impact the community and stakeholders.

Education

2003- December 2007 Bachelor of Science

Business Administration- Marketing

Winston Salem State University

Winston Salem, N.C.

Professional Skills

Ability to correspond to government requests, from payers such as Medicare and Medicaid, regarding overpayment audit findings and corrective action plans.

Ability to work with organization leaders to create educational materials to assist with compliant operational activities based on research of government regulations

Creating and implementing quality assurance measures as a result of audits and investigations

Auditing CPT and ICD-10 codes to ensure compliance with OIG and government payer requirements.

Above average MSWord, Access, Excel, PowerPoint skills. Skills with Magic, Macess, Amisys, NC Tracts, EPIC, RATSTATS and Blue E

Able to be creative and provide great team working skills and leadership.

Ability to overcome objections and negativity to accomplish a overall positive

experience

Achieved the ability to resolve, research and seek solutions for financial inquiries, benefit

responsibility and coverage for physicians and members, within given procedures in a timely

fashion

Ability to work investigation and audits within applicable CMS timeframes

Ability to maintain productive and accomplish goals while working remotely

Work Experience

Compliance Analyst

October 2024 (Full-time) Alliance Health

Analyzed and responded to employee Conflicts of Interest and Dual Employment forms

Assisted with editing company policy and procedures.

Assisted with presenting Compliance requirements for New Employee Orientation

Audited departments to ensure delegation results were documented in a timely manner and reported to the Compliance Team accurately.

Compliance Consultant

December 2014- August 2024 (Full-time) Novant Health

Researched the Federal Register Final Rule, OIG, CMS, and other government entities to gain knowledge of requirements and assist with implementing workflows, policies and procedures to ensure compliance for the medical group

Assisted medical group leaders with formulating rebuttals to finalized National/Local Coverage Determinations

Conducted annual audits based on the OIG workplan to ensure medical group compliance

Used critical thinking and analytical skills to retrieve data to ensure investigations and audits included the appropriate audit universe based on the scope of the review.

Communicated audit and investigation results to medical group leaders via memos, reports, and scheduled meetings and implemented quality assurance monitoring as a form of corrective action

Completed investigations within applicable timeframes that resulted in overpayments from government payers such as Medicare, Medicaid, and Tricare

Disclosed overpayments to Medicare, Medicaid, and Tricare by utilizing the appropriate processes and procedures for refunding inappropriate payments.

Responded to CMS and Medicaid correspondence regarding completed audits and additional requests while adhering to HIPPA guidelines

Conducted medical group trainings for audited clinics, at their request

Assisted with department policies, procedures, and trainings to ensure department expectations were accomplished.

Assisted with Conflicts of Interest meetings and disclosure process.

Assisted with submitting RAC appeals.

Stayed up to date with certifications and career growth by attending trainings, conferences and local AAPC meetings.

Medicare Appeals Analyst

September 2013-December 2014 (Full-time) Blue Cross Blue Shield of North Carolina

Processed grievances and appeals with in Medicare timeframes and departmental policies and procedures.

Prioritized case load based on appeal request to complete cases based on required timeframes and appellants need.

Used detailed research to investigate benefits, medical criteria, and claims to assist with the appeal or grievance.

Worked with other internal departments to make case determinations, approve authorizations and process claims.

Collaborated with doctors, medical staff and billing offices to collect pertinent information to support the case decision.

Worked beyond normal scheduled hours to complete expedited requests and complete case load based on the appellants need.

Received training and knowledge of Medicare guidelines

Collaborated with other team members to assist with cases and discuss any trends

Achieved monthly goal of closing at least 35 cases with no late cases

Achieved monthly audit goal on closed and open cases

Customer Service Specialist

April 2008-September 2013 (Full-time) Blue Cross Blue Shield of North Carolina

Created a customer friendly atmosphere while following procedures and guidelines.

Followed HIPPA regulations while satisfying the member’s and health care provider’s needs for clarification on benefits, eligibility, healthcare coverage and claims resolution.

Fulfilled administrative duties for members and health care providers while providing timely follow-ups.

Worked with various systems and departments to research member responsibility, refund/voucher deducts for providers, claims pricing per provider’s contract, appeals resolution and authorizations.

Assisted providers with CPT and ICD9 codes, including; authorization requirements, medical necessity requirements per medical policy, benefits application and claims filling guidelines.

Assisted member with calling providers to verify claims coding in relation to the member’s chart and service provided.

Served as back up Mentor in the absence of the primary Mentor. Also, assisted with completing team’s service request inventory and future activity call backs.

Appointed by peers to be a part of Professional Leadership Team for Customer Service Department.

Assisted the new hire training class with on the job training and class room training.

Volunteer Experience

2021-Current Event Planner/Grant Writer/ Assistant to Founder

Women of Wisdom/The House of Refuge, Winston Salem, NC

Assist the Founder with applying and qualifying for grants. Plan events, marketing materials and community activities for the organization throughout the year. Connect with community partners to ensure partnerships stay intact. Performed intake on women entering The House of Refuge.

2021-Current Event Planner/Grant Writer/Assistant to Bishop

Disciples of Grace Ministries, Winston Salem, NC

Assist the Bishop with planning appointments and scheduling. Assist with applying and qualifying for grants. Supervise the event planners with planning events throughout the year. Assist with marketing materials, website and community outreach activities. Connect with community partners to ensure partnerships stay intact.

2024-Current Vendor Coordinator

Winston Salem Fashion Week, Winston Salem, NC

Coordinate details, vendor layout and build relationships with vendors that participate in the events for the week.

References

Carolyn Morrison, Novant Health- 336-***-****

Keyra Faulkner, Wake Forest University- 336-***-****

Dr. Jon Houser, Disciples of Grace Ministries, Wake Forest, 336-***-****

Contact this candidate