Muslimah Bethea
Shallotte
Summary
Proven expertise in analyzing and resolving appeals with precision and efficiency. Skilled in applying strong analytical abilities to evaluate cases and pinpoint critical issues. Recognized for clear communication and collaborative problem-solving, consistently ensuring compliance and successful resolution. Backed by 19 years of customer service and support experience, delivering dependable results and client-focused solutions.
Overview
9
9
years of professional experience
Work History
Appeals Analyst- Commercial Appeals and Grievances
Blue Cross Blue Shield North Carolina
09.2024 - Current
- Analyzed complex claims to determine eligibility for appeals and resolution processes.
- Answer member/provider questions via incoming telephone calls in a professional quality driven manner.
- Collaborated with cross-functional teams to streamline appeal workflows and enhance efficiency.
- Reviewed documentation for accuracy, ensuring compliance with regulatory standards and internal policies.
- Research and investigate all aspects of the member and provider appeals and grievances, to ensure compliance with medical necessity criteria, Corporate Medical Policy (CMP), member and provider contract provisions, State and/or Federal requirements.
- Consult and confer with medical directors and other clinical staff to ensure the appropriate decision has been made and the approved outcomes are implemented.
- Identify, collect, and analyze appropriate documentation from multiple internal systems (Facets, Nuexo, Plan Connexion, Care Radius, Smart Desktop, including claims, customer contract management, benefit booklets.
- Initiate claim adjustments on individual cases when necessary and follow and track until completion.
- Provide written documentation of case determinations to appellants and/or all involved parties.
Customer Service Representative-Provider Services
Blue Cross Blue Shield North Carolina
07.2021 - 09.2024
- Receive incoming calls from BCBSNC Commercial, IPP HOST INTRA- PLAN, and Blue Card SMA providers.
- Assist with providing claim status and benefits (Including ASO members).
- Provide payment details on processed claims, researching refund and voucher deduction request.
- Communicating with various BCBS home plans (Intra-Plan) to ensure claim resolution.
- Provide status and research on all incoming correspondences for Commercial, IPP Host, and Blue Card SMA claims (Level One Appeals, Coordination of Benefits, Authorizations, and Medical Records).
- Strong knowledge of BCBSNC internal systems (Facets, Nuxeo, Hipaa Gateway, Doc Request, Plan Connexion, Bi-Portal, Provider Link, Care Radius, Macess, Smart Desktop, Mobius, and Amisys).
- Utilizing probing and creative problem- solving methods to resolve foundational provider inquiries on first contact.
- Identifying and obtain information and records from providers to correct and update member’s accounts pertaining to claims status and benefits.
- Educating providers on BCBSNC practices and policies.
- Assisted with Commercial New Hire benefits and eligibility training.
- Assisted with processing PIT Inventory.
Financial Services Representative
Capital Vacations LLC
11.2018 - 06.2021
- Make outbound and receive inbound calls on an auto dialing system from owners for collection of payment on delinquent Time Share accounts.
- Negotiate and set up payment plans.
- Process and review account adjustments.
- Accountable for reducing delinquency on assigned accounts to get current.
- Educate the owners on terms of sale and loan documents.
Claims Customer Service Advocate II/ Team Lead
Blue Cross Blue Shield of SC -PGBA
05.2017 - 11.2018
- Provided processed claim and health benefit information.
- Investigate and researched denied claims for services rendered.
- Assist with team escalations.
- Initiated, scheduled, and confirmed veteran's appointments and authorizations that were approved for the V.A. Choice program.
- Assist veterans and healthcare providers with self-serve options via Healthnet website.
- Updated demographic information.
- Obtained an active C2 security clearance through office management.
Education
DIPLOMA -
MEDICAL BILLING AND CODING College of Wilmington
Wilmington, NC07.2013
Associate Degree - undefined
Office Systems Technology Brunswick Community College
Supply, NC05.2004
Diploma - undefined
GENERAL STUDIES West Brunswick High School
Shallotte, NC06.1995
Skills
- Strong customer service skills
- Maintain strict confidentiality
- Strong oral and written communication skills
- Critical thinker
- Data-entry of patient/customer demographics
- Knowledge of Microsoft Word
- Knowledge of Microsoft Office
- Knowledge of Excel
- Knowledge of Windows
- Knowledge of Outlook
- Knowledge of Power Point
- Decision-making skills
- Claims knowledge
- Knowledge of CPT codes ICD-10, HCPCS
- Organizational skills
- Medical terminology knowledge
- Troubleshooting
- Problem Solver
- Case evaluation
- Teamwork and collaboration
- Insurance policy knowledge
- Time management
- Attention to detail
- Multitasking Abilities
Timeline
Appeals Analyst- Commercial Appeals and Grievances
Blue Cross Blue Shield North Carolina
09.2024 - Current
Customer Service Representative-Provider Services
Blue Cross Blue Shield North Carolina
07.2021 - 09.2024
Financial Services Representative
Capital Vacations LLC
11.2018 - 06.2021
Claims Customer Service Advocate II/ Team Lead
Blue Cross Blue Shield of SC -PGBA
05.2017 - 11.2018
Associate Degree - undefined
Office Systems Technology Brunswick Community College
Diploma - undefined
GENERAL STUDIES West Brunswick High School
DIPLOMA -
MEDICAL BILLING AND CODING College of Wilmington