Debra A. Jones7777 Normandy Blvd Apt 1218

Jacksonville, Florida 32221Mobile: 757-316-6328

Email Address: Jon7debor@aol.com

Resourceful and diverse producer with vast skills and abilities that span more than two decades in human services, Healthcare commercial insurance, Medicaid, Medicare, Medicare Advantage, Patient Services, sales, claims, the establishment of long-term lucrative relationships, comprehensive product knowledge and superior client services.

Interpersonal and articulate, able to pursue initiatives that capitalize on strengths and opportunities, and proven to successfully identify and shepherd the process from the first meeting to the closing of transactions.

Excel in the management and mentoring of others with an innovative approach that encourages and enables attainment/exceeding of imposed goals and objectives, a collaborative team approach and the desire to succeed.

PROFESSIONAL HISTORY

Provider Service AdvocateAugust 2015 – PresentFirst Coast Service Options- Jacksonville Florida

Respond to Medicare Part A telephone inquiries from the Medicare provider community regarding coverage guidelines and policies covering a wide range of topics to include provider enrollment, Medicare appeals, debt recovery, claim payment information, telephone reopening requests, and general coverage for multiple provider specialties. Access the IVR and Internet Portal systems as needed to help educate customers on self-service options that are available to them. Access the IVR and Internet Portal systems as needed to help educate customers on self-service options that are available to them. Analyze claim edits and audits to determine reasons for claim denials. Review local medical coverage and national medical coverage policies in order to troubleshoot reasons for claim denials and reductions. Review other system to address and determine resolution to other customer issues to include pending appeals, aged claims, and Medicare Secondary Payer. Customer Service. Engage in dialogue with all customers using a customer-friendly tone even when challenged with overly aggressive customers. Respond to each customer’s need and request and ensure each customer’s encounter is positive and productive. Use good verbal communication during each customer encounter and never use jargon and slang during customer calls. Embrace diverse backgrounds and understand the needs of those customers who may not have as extensive knowledge of Medicare rules and regulations. Tailor responses to ensure customers receive the maximum benefit when calling Medicare.

Utilization Management Manager 1December 2012 – April 2015Anthem BCBS –Virginia Beach VA

Provided supervision and technical support to the Medicare Advantage Case Specialists referrals team. Managed staff to meet or exceed department goals, including productivity metrics, quality and timeliness as defined by department guidelines. Monitor and manage call volumes. Ensuring that staff adheres to departmental guidelines, providing direct feedback and coaching. Supervise implementation of procedures in concert with contract requirements and federal and state laws. Serve as departmental liaison to internal and external associates and customers. Interact with other departments in development of technical training and user documentation to assist in the support and training of all staff. Facilitate training on systems and departmental policies and procedures. Lead team meetings to keep associates abreast of Company and Departmental activity. Recruit, hire, schedule, train, coach and manage Case Specialist team performance, ensuring compliance of all regulatory requirements.

Eligibility SupervisorOctober 2008 to August 2011First source LLC – Portsmouth, VA

Provided Staff Supervision to Medicaid/Disability Eligibility Service Reps, which included interviewing, hiring, and training new staff members, facilitated team meetings, scheduling, payroll, employee development, assigning work, direct activities, monitored work quality and performance evaluation, and issued performance improvement plans (PIPs) when necessary. Promoted public relations; resolved and provided timely responses to concerns, complaints, and conflicts. Assisted with contract implementations, managed program activities, monitored program compliance, gather information, analyzed data, evaluated trends, and developed plans of action. Monitored multiple databases to keep track of all company inventories. Created and prepared a variety of daily, weekly, monthly, and annual reports for distribution to management, administrators, staff, and client base. Made monthly visits to local sites, with frequent overnight stays to surrounding sites. Coordinated the delivery of services among various departments and service.

Substitute TeacherSeptember 2007 to October 2008Portsmouth Public Schools – Portsmouth, VA

Taught students basic academic, social, and other formative skills in public or private schools at the K-12 level. Followed and created lesson plans. Kept students on task during the absence of their permanent teacher. Created and maintained a climate of respect and fairness for all students.

Senior Outreach SpecialistJuly 1998 to April 2007

Anthem BCBS – Virginia Beach, VADeveloped and fostered partnerships and awareness in the community and state by educating and servicing existing and potential members, facilitated group presentations. Managed community outreach initiatives which included health information that promoted healthy lifestyles, developed communication strategies to increase awareness of health plan services and the community services that supported the Medicaid and Commercial population. Represented Anthem by participating on boards and committees of significant community organizations to increase awareness of the health plan. Coordinated community health fairs and special events. Made home visits to new and existing members. Identified and addressed barriers to care, and assisted clients with making appointments and needed services.

Provider/Member Service RepresentativeNovember 1996 – July 1998

Anthem BCBS Virginia Beach, VA

Handled inbound telephone inquiries Verified plan benefits and eligibility Investigated and resolved service issues Coordinated member transportation.

EDUCATION & LICENSES

Saint Leo University 2006Saint Leo, FLBachelor of Arts (BA)Major: Sociology/Minor Criminology