Medical Benefits Quality Assurance Analyst at Blue Cross & Blue Shield of Mississippi (2022-11 – Present)
- Audit medical claims and enrollment data for accuracy, compliance, and adherence to corporate quality standards.
- Analyze performance data to identify recurring errors, control gaps, and operational trends.
- Prepare quality reports and recommend corrective actions, system enhancements, and procedural improvements.
- Develop and execute test plans for policy, process, and system changes.
- Collaborate with management and training teams to update procedures and instructional materials.
Prescription Benefits Technical Quality Assurance Analyst at Blue Cross & Blue Shield of Mississippi (2019-08 – 2022-11)
- Validated pharmacy benefit plans, formularies, drug tiers, pricing, and claims configurations.
- Developed and executed quality assurance testing for more than 300 self-insured group plans.
- Performed functional, pricing, and system testing to verify accurate benefit configuration and claims processing.
- Identified, documented, tracked, and retested system defects through resolution.
- Partnered with technical and operational teams to support successful system implementations.
Quality Assurance Analyst at Blue Cross & Blue Shield of Mississippi (2013-01 – 2019-08)
- Monitored Federal Employee Program, Inter-Plan, and local claims operations for compliance with established standards.
- Compiled and analyzed quality data to identify workflow weaknesses and processing trends.
- Produced performance reports and recommended system, procedural, and operational improvements.
- Supported system testing, implementation activities, and departmental quality initiatives.
Senior Claims Specialist at Blue Cross & Blue Shield of Mississippi (2005-10 – 2013-01)
- Evaluated complex, high-dollar, and suspended medical claims requiring advanced interpretation of benefits and policies.
- Investigated processing discrepancies and analyzed claims data to identify systemic issues.
- Ensured compliance with federal, state, organizational, and contractual requirements.
- Trained junior claims processors and contributed to internal processing guidelines.
Claims Specialist I and II at Blue Cross & Blue Shield of Mississippi (1998-07 – 2005-10)
- Reviewed and processed medical claims, adjustments, coordination-of-benefits cases, and overpayment recoveries.
- Investigated eligibility, documentation, payment, and benefit discrepancies.
- Responded to inquiries from members, providers, and participating health plans.
- Consistently met quality, productivity, compliance, and turnaround-time standards.
