Experienced Claims Quality & Customer Service Lead

Objective

To acquire a position with an opportunity for professional growth in a people-oriented organization where advancement is based upon skills. Education and contributions.

Skills

Office Skills: MICROSOFT WORD; POWEPOINT;EXCEL; ACCESS; CPS; ONBASE; GENSYS; U4ME; CQP; SEAL; INTEL; ADMINSTATIVE PORTAL;

Professional Experience

UMR-Cincinnati, OH (04/25-Current)

Internal Claims review

Worked in the claim quality portal in order to pull on assignments

Accessed GJAH to pull up the claim edits

Calltrack was accessed to check for documentation of the claim processing

Onbase was used to check for notes, appeals FYAA documentation and pre-cert

Pulled up the HPDB in CPS to verify how/why the benefits are/aren’t paying as they should

Completed question sheet for questions, I may have during the auditing process for instructions

UMR-Cincinnati, OH (03/24- 04/25)

Customer Service (Team Lead)

Training new Customer Service representatives to achieve quality customer service

Assist Customer service representative in zero check on their claims processing

Equip the customer service representative that are assigned to my Supervisor with the tools to make the most beneficial decision when approached with claims and benefits question via bridge, side chats, Emails

Assist with Bi-weekly team meetings

Provider (chairside) for new hires and the team member with low quality scores listening to calls as well as taking call to show the direction in which a call should go

Ability to successfully multitask through multiple systems as well as operate the programs given I.E WEBXE, VCC, Onbase, knowledge central, emails and others efficient tool

Complete the quality check for the representative on my team and advise if a rebuttal should be completed or if they are to accept the error for the claims sent to Quality

Work the SEAL reports and provide feedback if required

Assigned all the claims for 2nd review, zero check and daily assignment completed in a timely manner and or sent back to reps for error completion

UMR-Cincinnati, OH (09/19- 03/24)

Customer Service Specialist

Written and oral communication to achieve the best benefits for the Customers we service, Members and providers

Assisting the provider with the claim’s processing questions, payment and/or denial and providing documentation

Verbally provided Members and Providers benefit information to be able to make the best medical decision for their plan

Creating documentation through our system to communicate with other staff, I.E Sup, Leads and other Customer first reps

Processing Claims and assuring that they are processed correctly

Ability to successfully multitask through multiple systems as well as operate the programs given I.E webEx, VCC, Onbase, knowledge central, emails and others

Education

Cincinnati State Technical College- Cincinnati, OH

Major Studies: Early Childhood Development

Cincinnati State Technical College- Cincinnati, OH

Major Studies: Business Management

Gateway Technical and Community College- Covington, KY

Major Studies: Human Services

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