Davida Smith Email & Phone Number

Manage the accurate and timely adjudication of claims and administers claims in accordance with contractual benefits and health care policies. Responsible for managing daily work queues, quality of claims processed and final resolution. Monitor claim turnaround times to assure all compliance guidelines are met as well as performance guarantees.Determine benefit eligibility on suspended claims and review claims history and other information to determine whether suspended claims should be paid, denied, or sent for medical review.Review claims for possible “fraud” and send to Special Investigations Unit for additional investigation. Place outbound calls to Providers as needed.Assist management by identifying and analyzing opportunities for improvements in BCBSNC processes, policies and services. Coordinate with other insurance carriers and Medicare to determine BCBSNC payment liability.Identify system problems, including documentation of the issue, recommendation of potential solutions, referral to appropriate technical staff and follow-up to ensure resolution.

Address and resolve customer service inquiries and problems from members, providers, and plan sponsors via telephone, internet or written correspondence. Assign and direct issues and inquiries to appropriate staff. Document and track contacts and calls in system of record.Explain member's rights and responsibilities in accordance with contract. Respond to requests received from Aetna's Law Document Center regarding litigation; lawsuits. Address incoming requests for appeals and pre-authorizations not handled by Clinical Claim ManagementProcess claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) via target system.Performs review of member claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductible. Performs financial data maintenance as necessary.Analytic duties include handling extensive file review request, assisting in the preparation of complaint trend reports, and compiling claim data for customer audits.Determines medical necessity, applicable coverage provisions and verifies member plan eligibility relating to incoming correspondence and internal referrals.

Processed prescription & medical id cards for benefit recipients. Maintained computerized databases in Excel and other custom software to ensure up to date address and employee information. Scanned & indexed ID card information for ID card creation.Processed new group, renewal, and consultant memo requests for benefit services to determine their service requirements & create appropriate benefit cards. Reviewed error logs to ensure files uploaded correctly & investigate errors in file transfer.Performed daily audit of cards entering mail processing to ensure correct customer information. Performed daily upload of prescription files in proprietary software systems including but not limited to Catalyst, Pharmavail, Scriptrax, & Pharmacare.

Ba, Management And Business Ethics

Diploma, General Education