Quality Assurance Specialist
Resume:
Whitney Coleman
Contact
**** ********** **** *** *** 4412
Charlotte NC 28213
************@******.**
Objective
Detail-oriented Quality Assurance Specialist with over 10 years of experience in claims adjudication, membership eligibility auditing, and operational compliance within healthcare and pharmacy benefit management. Adept at conducting quality reviews, identifying process inefficiencies, and implementing improvements to enhance accuracy and timeliness. Strong background in utilizing QA tracking systems and collaborating with cross-functional teams to ensure regulatory compliance and operational excellence.
Key Skills
Proficient in
DB2, VBA, SQL
Microsoft Office
Kronos
Salesforce
QNXT
CRM
Verint
Docutrack
Microsoft Teams
Video Conferencing
CVS Caremark
Availity
Experience
August 2023 – Present
Patient Care Advocate • Sagility Healthcare
Gather, analyze and report verbal and written member and provider complaints, grievances and appeals
Prepare response letters for member and provider complaints, grievances and appeals
Data entry and Maintain files on individual appeals and grievances
Administered and supported health and welfare benefits programs, ensuring compliance with company policies and regulations.
Reviewed, verified, and processed pharmacy invoices for payments, maintaining accuracy in financial transactions.
Analyzed and evaluated large datasets to identify discrepancies, resolve issues, and improve process efficiency.
Collaborated with internal teams to streamline pharmacy benefits administration and enhance employee experience.
Developed and implemented solutions to address invoicing errors, data accuracy challenges, and benefit administration concerns.
Maintained detailed records and reports related to pharmacy benefits and invoicing for auditing and compliance purposes.
Insurance verifications, pharmacy claims review, prior authorization initiation
January 2023 – August 2023
Claims Processor • Alma
Processed and adjudicated complex claims while ensuring compliance with regulatory and internal guidelines.
Monitored and identified processing inconsistencies, suggesting workflow optimizations to improve efficiency.
Conducted routine audits of claim payment accuracy and coordinated with management to address systemic errors.
Supported the creation of new process documentation to improve training and overall team performance.
Maintained in-depth knowledge of claims policies, job aids, and regulatory requirements.
January 2021 – December 2022
Technical Support • Capital One
Provide live phone support and chat support to the employees, employee onboarding/offboarding, technical expertise and timeliness. Provide remote IT assistance for maintenance of Windows workstations. With moderate supervision, take ownership of an issue and follow through on a resolution with end users and other pertinent IT staff. Respond to end-user issues and requests via the helpdesk ticketing system. Track support calls in the Help Desk ticketing system. Adhere to established standards and procedures in resolving problems.
April 2017 – December 2020
Training Coordinator • Receivable Solutions Inc
Developed individualized and group training programs that address specific business needs. Evaluated organizational performance to ensure that training is meeting business needs and improving performance.
Guided clients through budgeting and debt repayment strategies, empowering them to make informed financial decisions.
Utilized active listening and problem-solving skills to address client concerns and reduce attrition rates.
Developed customized financial plans aligned with clients' goals and presented realistic solutions to improve financial well-being.
Maintained comprehensive and accurate client records within CRM systems, ensuring data integrity.
Achieved retention benchmarks by proactively engaging clients and anticipating their needs.
December 2007- March 2017
Supervisor Provider Services • Blue Cross Blue Shield
Execute licensure and credentialing processes for new and existing providers.
Report licensure and credentialing expiration dates and renewal requirements to the providers Ensured data quality and integrity by performing regular audits and data cleaning processes in compliance with HIPAA and other healthcare regulations.
Education
Limestone College, AS Computer Science
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