Experience

Alliance Health

• United States
• Hospitals and Health Care
• 500 - 600 Employee

• EDI Technical Specialist

  • Mar 2023 - Present



CSC

• United States
• Information Technology & Services
• 700 & Above Employee

• EDI Operations Business Analyst

  • Aug 2012 - Aug 2023

  - Apart of MMIS Replacement project for NC Medicaid - Work with Trading Partners to test and certify HIPAA X12 and D.0 submission - Validating HIPAA 5010 requirements via Edifecs - Ramp Management Portal - Testing Trading Partners for compliance with Companion Guide requirements - Management of Edifecs Ramp Management Web tool - Management of EDI Support / Resolution Center - EDI Tech Support: Resolution of Transactions Specific Errors/Failures - EDI Problem Resolution / Management (Connectivity Issues) Show less



Blue Cross NC

• United States
• Insurance
• 700 & Above Employee

• Supervisor - Provider Service Consultants

  • Feb 2010 - Jun 2012

  - Primary role is to lead a professional team of five consultants across the state of North Carolina to address the needs of escalated claims/operational issues, as well as, educate providers on BCBS of NC claims processing guidelines, procedures, and e-resources. - Secondary role is to direct a team of four provider service associates to handle all escalated claim/service issues from the customer service area. - Working as a liaison between BCBSNC and the provider, we are tasked with knowing contractual language and applying it to various claims issues and/problems. - Additionally, this team is tasked with compiling claims and contact data to present before providers, to help develop process improvement guidelines and procedures. - Extensive experience in presenting in front of various audiences in both the provider side (healthcare facilities and professional offices), and at annual provider conferences. - Regularly pulled data and analyzed claims information to determine trends for possible issues and/or process improvements within internal systems/process or for contracted providers. Show less

• Provider Service Consultant

  • Jul 2009 - Feb 2011

  - Primary role was to manage a dedicated BCBSNC onsite service team for the WakeMed Hospital system. Responsible for managing a team of two operations specialists and medical review nurse onsite at the WakeMed business offices. We handle all post-adjudicated claim inquiries, both for local business and out of state business. - Working as a dedicated consultant to a key provider, I also helped coordinate monthly meetings and provided regular reporting on the progress of the onsite service model. - Worked as a liaison between BCBSNC and professional providers in the healthcare network. Provide training and problem resolution to various issues that may occur in providers’ offices and/or facility settings. Issues included escalated claims inquiries, EDI transaction inquiries, process improvements, compliance questions, regular data analysis and reporting, and education/training centered around claims processes and/or EDI resources. Show less

• EDI Consultant / e-Solutions Consultant

  • May 2007 - Aug 2009

  Working in Commercial & Government Operations in the claims/e-Solution area of BCBSNC.Understanding the health care provider office experience and knowledge of ASC x12N 837, 835, 27X transactions. Provided maintenance, training, marketing, and customer service support for providers and group customers using our electronic communication network (Blue-E). Supported local professional service team, providing EDI expertise and consulting for key managed care providers (UNC-Duke-WakeMed-FirstHealth systems)Comprehension to read, interpret and communicate technical information to customers as is necessary. Built a working knowledge of group operations, the communication network, coverage and benefits of administered programs (underwritten and Medicare), claims processing systems (BCBS and Medicare Adv.). Working knowledge of providers' business office practices and procedures to research provider issues. Show less

• e-Solutions Consultant

  • May 2007 - Jul 2009

  The e-Solutions Consultant teams with the e-Solutions Internal team to provide maintenance, training, marketing, and customer service support for providers and group customers using our electronic communication network (HIPAA transactions-On-line Resources). They support their local Professional Relations office team, providing EDI expertise and consulting for key managed care providers.

• Network Management Coordinator

  • Nov 2005 - May 2007

  Training and education of BCBSNC resources for doctors' offices. Building relationships with healthcare/hospital facilities to help them serve BCBSNC members. This role also has the responsibility of handling any issues related to specific claims inquiries, as well as, member issues.



BCBS of North Carolina

• Network Management Coordinator

  • Nov 2005 - May 2007

  Worked as a liaison between BCBSNC and professional providers in the healthcare network. Provided training and problem resolution to various issues that may occur in provider's offices and/or facility settings. Claim research and usage of contractual code-logic/verification software are some of the many skills that were required to be able to research and resolve provider's claims and/or contract issues. Worked as a liaison between BCBSNC and professional providers in the healthcare network. Provided training and problem resolution to various issues that may occur in provider's offices and/or facility settings. Claim research and usage of contractual code-logic/verification software are some of the many skills that were required to be able to research and resolve provider's claims and/or contract issues.



Capital Marketing Group

• New Business Acct. Rep

  • Aug 2004 - Oct 2005

  Overseen the contracting division for over 1,000 agents with multiple life insurance companies. (Contracts - Annuities -Variable & Fixed, Life, and securities) Promoted to New Business department - overseen the processing of all life insurance (Term & Universal Life), annuity, and 1035 Exchange/Replacement applications. Overseen the contracting division for over 1,000 agents with multiple life insurance companies. (Contracts - Annuities -Variable & Fixed, Life, and securities) Promoted to New Business department - overseen the processing of all life insurance (Term & Universal Life), annuity, and 1035 Exchange/Replacement applications.



Partners & Blue Cross & Blue Shield of NC

• Network Development Assistant

  • Oct 2001 - Jul 2002

  Reviewed and assisted in the negotiation process of contracts for the eastern region of the state. Researched and compiled fee schedules for the negotiation process of contracts. Extensive research of coding and claims reconciliation based on contractual arrangements. Self-educated on new claims and credentialing software. Handled telephone calls from providers, dealing with problems of claims reimbursement issues and/or verification of credentialing information. Reviewed and assisted in the negotiation process of contracts for the eastern region of the state. Researched and compiled fee schedules for the negotiation process of contracts. Extensive research of coding and claims reconciliation based on contractual arrangements. Self-educated on new claims and credentialing software. Handled telephone calls from providers, dealing with problems of claims reimbursement issues and/or verification of credentialing information.



PARTNERS National Health Plan

• Network Management Assistant

  • Aug 2000 - Oct 2001

  Extensive research of coding and claims reconciliation, and servicing-specific issues with providers. Conducted site surveys of new participating physician offices. Reviewed and assisted in the negotiation process of contracts between the company and providers. Handled all logistics of credentialing information from providers for the company's credentialing process for the eastern region of the state. Extensive research of coding and claims reconciliation, and servicing-specific issues with providers. Conducted site surveys of new participating physician offices. Reviewed and assisted in the negotiation process of contracts between the company and providers. Handled all logistics of credentialing information from providers for the company's credentialing process for the eastern region of the state.



East Tennessee State University

• United States
• Higher Education
• 700 & Above Employee

• Internship

  • Aug 1999 - Dec 1999

  Participated in various projects - ex. Business proposals ($500,000) & Customer and employee satisfaction surveys. Attended classes/meetings and learned management/leadership theories and skills. Received education on continuous improvement theories and methods. Participated in various projects - ex. Business proposals ($500,000) & Customer and employee satisfaction surveys. Attended classes/meetings and learned management/leadership theories and skills. Received education on continuous improvement theories and methods.