Marcus Flake Email & Phone Number

Process claims and adjustments identified in service requests from Customer Service.Review and research incoming healthcare claims from providers (doctors, clinics, etc.) and verify the data/information necessary for processing (e.g. pricing, prior authorizations, applicable benefits).Identify, analyze and resolve common, complex, and escalated operational issues impacting professional, hospital, ambulatory surgical center, and ancillary providers or the members and groups that they serve.Identify and document global and/or systemic problems, gaps, or inconsistencies in workflows, and/or processes based on collected information related to provider issues and provides recommendations for updates, alternatives and/or solutions.Provide analysis and feedback for technologies, trends, best practices, and service offerings to incorporate them into overall stakeholder business solutions.Provide coaching and feedback to customer service and claims departments regarding claims and claims errors.Educate and encourage providers on use of alternative delivery channels including self-service, Blue E, web, etc. Educate providers on acceptable BCBSNC practices and policies.Provide cross functional support between the provider and various areas within the Plan including local, state and federal government entities across all lines of businessEffectively manage inventory to meet departmental goals and Service Level Agreements (SLA)Handle special projects or requests from Provider Service Consultants and Coordinators as necessary.Manage team mailbox and escalation phone line to address issues received from the Provider Service Consultants and Coordinators, Network Management, and the Leadership Team.

• Utilize probing and creative problem solving as well as critical thinking and the ability to analyze complex and ambiguous information to resolve customer inquiries on first contact. Document corrective measures and provide instructions as needed to internal business areas to ensure prompt resolution and response to customer inquiries.• Identify and obtain information and records from customers, members, providers and/or employer groups to correct/update information, claims records when necessary.• Recognize patterns of inconsistent and/or inaccurate claims filing practices among customers and providers, educate customers and providers on acceptable BCBSNC practices and policies.• Review and research incoming healthcare claims from providers(doctors, clinics, etc) by navigating multiple computer systems and platforms and verifies the data/information necessary for processing (e.g. pricing, prior authorizations, applicable benefits)• Process claims and adjustments identified in service requests from Customer Service• Communicate and collaborate with providers to resolve issues,• Review and research incoming healthcare claims from providers by navigating multiple computer systems and platforms and verifies the data/information necessary for processing• Meet or exceed established quality and performance standards• Provide coaching and feedback to customer service department regarding claims and claims errors.• Conduct huddle sessions to discuss how to effectively and efficiently research a claim

Consults with Medical Directors and clinical staff regarding utilization management and post decision inquiriesProvides cross functional support between membership, sales and underwriting departmentsActs as the first level supervisor of provider escalations for more complex and urgent inquiresProvides coaching and feedback to our Customer Service ProfessionalsAnalyzes current benefit plans and contracts for providers and membersEvaluate effectiveness, cost, and service against members contracted benefits for medical carePrepares weekly/monthly escalations and trend reports for senior management Investigates and process medical claims with denials and coding issuesExceed company matrix’s of 93% on adherence and qualityReviews all fully & self funded lines of business (ASO, IGO, IBO, State PPO) December 2014 recipient of World Class Call Quality Auditor job shadowing March of 2015 Apply issue diagnosis to rectify issues in regards to members claims and or benefitsEmploy de-escalation techniques to reduce animosity and angriness over the phone

Verified benefits and eligibility for providers calling inbound to call center Specialized in medical claims status verification Reviewed claims with CPT coding and diagnosis for denials and status Exceeded quality expectation on audits (Monthly average 95%) Maintained company adherence of 93% on monthly basis Educated providers and member of option available to maximize benefit usageServed as back up supervisor to other Customer Service Professional with escalated matters

Managed daily profits of the branchAnalyzed all reports, cash accounts, and other vital financial operations Recruited and review application prospects for selection and hiring of staff membersImplemented training of branch operations to increase performance of daily operationsCoordinated activities to reach required company goalsReduced fraudulent activity among accounts by 20%Conducted workshops on medical, pension and other employee benefitsManaged payroll systems and function to provider timely service for payment to stakeholders and employeesPrepared monthly analytical reports