Collaborate with business area to coordinate testing plans.Manage business relationships, testing activities, ensuring testing meets business requirements.Document and execute test plans/scenariosAnalyze and verify testing results for accuracy, relevance, and completeness.Monitor configuration for accuracy and compliance to change control processes.Initiate impact assessments, formulating recommendations to clients regarding risks and issues.Execute and manage Sequel (SQL) queries to provide data and issue resolution.

Facets Configuration Oversight

Core Business Solutions Management

NCTIO

Identified, analyzed, and resolved all operational issues impacting our stakeholders while suggesting the appropriate Stakeholder Service Model to increase customer satisfaction and reduce administrative costs.Assisted in the analysis of all products and identified any deficiencies and made recommendations for improvements.Provided analysis and feedback for trends, best practices, and service offerings to incorporate into overall stakeholder’s business solutions.Planned and represented BCBSNC at on-site visits with stakeholders to educate, relay and review medical or administrative policies and procedures and to address their concerns and non-compliant contract or administrative issues requiring corrective action.

Researched complex provider claims issues and adjusted claims as needed.Recognized patterns of inconsistency and/or inaccurate claims filing practices among providers and educated providers on acceptable BCBSNC practices and policies.Worked as part of the team to determine root cause and made recommendations for operational improvementsIdentified and documented system problems, gaps, or inconsistencies in workflows, and/or processesPresented impacts and risks to the appropriate Claims leadership, Provider Service Consultants and Network Management teams.

Worked on the AIM vendor recovery project for overpayments made in error.Trained and provided education to AIM provider representatives and Jacobson contract employees assisting with the recovery of funds.Conducted quality monitoring and provided face to face feedback to team members and contract employees.Assisted in coaching and development of Financial Recovery Specialist in the areas of analytical problem solving and research skills for claim issues.Maintained confidential reports regarding employee performance.

Processed claims transactions for all lines of business that related to provider and subscriber refund requests and adjustments.Handled coordination of benefit issues and other party liability claims transactions.Assisted with non-standard pricing of claims and other special circumstances.