SERVICE ADVOCATE IV- CLINICAL SUPPORT Summary Over 10 years insurance industry experience. Strong analytical, documentation research skills. Highlights Extensive insurance industry regulatory compliance knowledge. Quality assurance conducting audits experience. Analyze issues, tack trending implement process improvement ideas. Research, develop, editing publish procedures department. Strong interpersonal communication skills Report writing Experience managing complex time sensitive projects. Provide important communications regard updates procedures. Claims file management processes Medical terminology specialist Database management All Lines Claims Adjuster Licensed 6-20 State Florida Experience Company Name City State Service Advocate IV- Clinical Support 01/2015 Current • Assist providers entry update requests medical clearances • Research, coordinate resolve inquiries claims exceptions • Coordinate Provider Service areas identify formal education opportunities • Identify, document monitor process improvements •Maintain records, reports, files • Moderate heavy keying required. • 9+ years' experience health insurance, provider's office (handling medical coding, filing insurance claims referrals) managed healthcare telephone service center • Experience working healthcare products including researching resolving provider inquiries working provider contracts networks • Experience working medical terminology, CPT-4 coding, ICD-9 coding claims adjudication inquiry resolution processes procedures • Experience working BCBSF healthcare products *Review contract benefits approve services claims payment. *Examine claim forms records determine insurance coverage *Verify investigative information *Maintain insurance records Company Name City State Service Advocate V- Sales Support Agent Service 08/2013 01/2015 Knowledge lines business include Over 65, MIPPA, Medicare Advantage, Under 65 Health Care Reform plans, BlueCare HMO, Blue Options PPO, Blue Select PPO, Underwritten plans, Ancillary products Dental Life, Small Large Group, Claims. Processing systems experience Detailed knowledge enrollment processes work flow Assist agents day day inquiries Train educate agents products, procedures applicable rules regulations. Research resolve system issues agent may have. Research resolve inquiries sales-related service -related lines business health ancillary products. Research information implement solutions sales partners whose needs demand agility persistence. Collaboration relationship building external partners, sales agents, brokers, consultants, key accounts, providers vendors. Experience working Sales Sales Operational areas Demonstrated experience managing multiple priorities demands. Company Name City State Service Advocate IV- Enrollment Maintenance Billing 03/2007 08/2013 Knowledge lines Over 65, MIPPA, MedAdvantage, Under 65 Healthcare Reform plans include BlueCare HMO, Blue Options PPO, Blue Select PPO, Underwritten plans, Ancillary products Dental Life. Document, monitor track call performance compliance Create, track implement identified process improvement items. Create reports upper management identify delays estimated completion dates actual implementations. Monitor Inventory timeliness, research outliers. Prepare SQM research, collecting summarizing data, identifying trends root cause analysis. Serve SME internal external customers resolve consumer market enrollment, maintenance, membership billing issues. Leader Senior Market Continuous Improvement Team: Supports continuous improvement efforts early identification, investigation resolution problems communicating coordinating appropriate contacts completion. Serving Process improvement work group Project management implementation process improvement items. Monitor Supervisor callbacks multiple locations timeliness completion within metrics handle escalated issues, etc. Invoices reconciles premium income. Maintain knowledge government regulatory laws changes. Education All Lines Claims Adjuster 2014 Florida State College Jacksonville City State 6-20 All Lines Claims Adjuster Bachelor Arts Psychology 2004 University North Florida City State Psychology Social Welfare Minor Strong analytical, organization, research, communication documentation skills. Bachelor Science Nursing 2001 Jacksonville University City State USA Nursing Submit claims items, document progress patient throughout care. Create plan care document progress discharge. Associate Arts Psychology 2000 St Johns River Community College City State Strong writing skills actively wrote college newspaper. Skills Healthcare: claims authorization, computerized paper claims submission People skills: advanced problem-solving, great organizational skills