ASSOCIATE CLAIM PROCESSOR/MEMBER SERVICE ADVOCATE Summary After 29 years' working industry puts people forefront business, I proven track record building maintaining relationships impeccable customer service background. My objective continue put people first, build strong long last relationships use expertise customer service field, give customer exceptional experience. Skills Customer service Verbal written communication Team collaboration Problem solving decision making Strong Analytics Strong work ethic Working independently team environment Strong leadership Interpersonal skills Experience 05/2013 Current Associate Claim Processor/Member Service Advocate Company Name － City State Receive calls customers regarding coordination benefits Respond accurately promptly customer concerns Update system additional insurance information Initiate calls providers verify request additional information required accurate processing Keep records customer transactions detail comments inquiries Organize customer inquiries meet specific time frames Examine new claims pertinent information required initial claim entry. Evaluate apply policies procedures implemented processing claims. Review execute request internal departments, providing feedback findings Research execute adjustments claims processed incorrectly Resolve claim suspends using proper reference guides systems resolution. Accountable researching history records determining claim processing issues providing claim status lead processor supervisor Review claims Coordination Benefits Medicare, Medicaid, insurance carriers Collaborate daily supervisor's, team leads team members, provide exemplary service customers 07/2011 05/2013 Claim Processor Company Name － City State Evaluated new provider customer claims information required processing. Identified claim discrepancies determined appropriate resolution processing. Determined claims returned, denied, adjudicated based policy procedure manuals. Trained temporary staff new hire employees claim processing, policies procedures, system applications. Provided feedback management regarding progress temporary staff new hires gave additional training assistance needed. Reviewed resolved claim inquiries regarding under/overpayments, benefits, pricing rate issues. Manually priced claims based provider contract required information. Participated tested new systems implementation configuration Highmark applications prior turnkey. Evaluated tested new managed care software programs development procedures used verify programs function according user requirements. Performed plan testing produced status updates management. Systems used: TBS, BlueChip, IDM, ITS/Formats, BlueSquared, OCR. 07/2010 07/2011 Customer Service Representative Company Name － City State Managed customer provider calls regarding benefits, eligibility claims. Reviewed benefits understanding applications benefits. Requested identification cards Certificates Credible Coverage. Collaborated providers resolving claims issues effort provide excellent service members. Provided timely resolution callback provider's customers regarding concerns. Assisted members online navigation BCBSDE website assisted providers NaviNet. Systems used: TBS, BlueChip, IDM, ITS/Formats, Avaya Phone system. 01/2008 07/2009 Team Lead/BlueCard Host Adjustments Company Name － City State Provided subject matter direction team members assisted complex claim issues. Educated team new claim processes, new updated procedures, system updates. Performed audits randomly selected letters sent provider's. Provided assistance supervisor managing workflow delegating work based expertise. Reported systems issues benefit discrepancies IT configurations analyst. Developed modified letters providers contacted Home plans regarding claim issues. Participated compiling production reports timesheets management. Reviewed responded inquiries providers BlueCard plans requesting adjustments claims underpaid overpaid. Maintained production quality standards. Systems used: WGS, Inter-plan Messaging, Facets, ETM, Ultera, NetWorx, Citrix. 04/2007 01/2008 EDI Enrollment Specialist Company Name － City State Identified resolved discrepancies enrollment applications group transmittals. Processed request additions, changes, reinstatements, terminations. Requested additional information needed marketing representatives, groups, members. Analyzed group enrollment forms rate tier changes, updated MHS, Facets, MSIQ, SLIQ. 12/2005 04/2007 Underwriting Assistant Company Name － City State Acted liaison verify, research, track monitor specific case issues. Prepared information MGU specific, aggregate, benefits, census reports. Reviewed census, specific, aggregate reports correct calculations. Followed client request acted liaison customer underwriter. Provided support underwriters quotation process new business. Gathered input data Sales Underwriting systems monitor track quote activity. Education Training Present Behavioral Science Wilmington University Behavioral Science 1988 Accounting Franklin Morris Business Academy Accounting 1983 Diploma General Studies John W. Hallahan Catholic High School General Studies Skills analyst, Avaya, Benefits, Citrix, client, direction, forms, IBM, insurance, letters, mainframe, managing, marketing, Messaging, SharePoint, navigation, OCR, Phone system, policies, pricing, processes, progress, quality, researching, research, Sales, supervisor, underwriter, Underwriting, website, workflow