Workforce Management Analyst/RTA at Elevance Health/Anthem BC/BS (2021-01 – 2024-12)
Responsible for performing real-time analysis and scheduling functions, monitoring call volume and ASA, and managing workforce operations.
- Responsible for performing both real-time analysis and scheduling functions as determined by current business need by monitoring call volume and ASA and adjusting schedules as needed to ensure consistent service is maintained.
- Develop a set of priority rules that will govern how shifts are assigned, to best distribute the staff to meet projected call volumes.
- Attending/leading weekly and daily staffing review meetings with operations management and other workforce disciplines.
- Completing and managing schedule exceptions/adjustments for the company daily by reviewing WFM mailbox/ticket log.
Outreach Care Specialist II – VA Medicaid/Behavioral Health at Anthem BC/BS (2013-01 – 2021-12)
Managed inpatient member census, coordinated behavioral health services, and processed authorizations for outpatient behavioral health services.
- Sort Daily Census and assign all unassigned inpatient members
- Contact members and providers after care to ensure proper follow-up documentation/treatment was sought.
- Review and enter Behavioral Health hospital admissions daily from Medicaid Excel Daily Census report into a Microsoft Access Follow-up after Hospitalization database.
- Sets up authorizations in FACETS for Outpatient Behavioral Health Services for In-Network/Out of Network Providers.
- Reviews of claims for specialty codes focused HCC audits and contacts Prospective Risk Adjustment Members to help coordinate care and services.
Customer Service Representative II – VA HMO Call Center at Anthem BC/BS (2006-01 – 2013-12)
Handled inbound calls from members and providers, processed claims, and provided customer service support.
- Handled inbound calls from Members and Providers regarding benefits, eligibility and claims in addition to providing knowledge of policies, procedures and products.
- Reviewed processed claims for errors, if an error is found then initiate interaction with other areas to ensure claims are corrected and resubmitted.
- Lead contact person for researching ECRP claims and removing Pre-existing from policies.
- Assisted with the Interviewing of potential candidates
- Assisted with Manager Calls and performed other duties as assigned
Claims Analyst II at Trailblazer Health Enterprises (2004-01 – 2006-12)
Researched and processed Medicare Part B claims using OCR and EMC systems, determined claim disposition, and resolved system edits and errors.
- Researched and accurately entered Medicare Part B manual paper claims by Optical Character Recognition (OCR) and Electronic Media Claims (EMC) suspense systems.
- Determined whether to pay, deny or return a claim as un-processable based upon established processing procedures and guidelines.
- Independently resolved system edits audits and claims errors through research and use of approved references and investigational sources: Med text, Multi-Carrier (MCS), Help File and Automated Development System (ADS) Process.
- Developed and maintained a working knowledge of Medicare rules/regulations and newsletters, medical terminology, anatomy, diagnosis and procedure coding through departmental training and education. Also performed other duties as assigned.
