MELANIE FLOWERS

Phone: 313-909-4748 E-Mail: mel020787@gmail.com

EDUCATION

BACHELORS IN SOCIAL SCIENCE, MINOR IN HEALTHCARE MANAGEMENT2017

University of Maryland University College – Adelphi, Maryland, United States

PROFESSIONAL OVERVIEW

HEALTH CARE PROFESSIONAL WITH FOUR (4+) YEARS OF EXPERIENCE. HAS KNOWLEDGE AND EXPERIENCE IN HEALTH MAINTENANCE ORGANIZATIONS, MEDICAID, MEDICARE, PREFERRED PROVIDER ORGANIZATIONS, AND HEALTH INSURANCE MARKETPLACE. SALES EXPERIENCE IN RETAIL AND CUSTOMER CARE FOR ELEVEN (11+) YEARS. SKILLED RESEARCHER AND ANALYST THAT MAINTAINS COMPLIANCE AND UNDERSTANDS HEALTH CARE REGULATIONS. EXTENSIVE EXCEL DEVELOPMENT THAT INCLUDES SKILLS IN MAINTAINING ACCURATE EXCEL SPREADSHEETS, WITH PROFICIENCY IN MACROS, VLOOK-UP, EXCEL ADD-INS AND MAIL MERGE. PROFICIENT IN MICROSOFT ACCESS QUERIES AND CREATING REPORTS. EXCELLENT INTERPERSONAL, ORGANIZATIONAL, ANALYTICAL, AND PROBLEM SOLVING SKILLS.

PROFESSIONAL HIGHLIGHTS

PROFESSIONAL EXPERIENCE

BUSINESS ANALYST OCTOBER 2015 – CURRENT

Strong analytical skills Effective in a team environment Strong interpersonal communication

skills Microsoft Word, Excel, PowerPoint,

Access, and Outlook proficiency Medical terminology Two (2+) years of HEDIS extraction Maintain strict confidentiality Community Outreach

Schedule management EMR and EHS proficient Knowledgeable in HMOs, PPOs,

Medicare and Medicaid Insurance operations

Four (4+) years of health care experience

Three (3+) years of collecting and analyzing health data/reports

Two (2+) years or training experience Extensive research skills

Blue Cross Blue Shield – Detroit, MI – Contracted

Staying in compliance with the Health Insurance Marketplace regulations to avoid fines or loss of state contracts.

Evaluating complaints to analyze whether an investigation is necessary, and when appropriate lead and participate in those complaint investigations by conducting extensive research.

Following up with customers to evaluate adverse events and acquire other pertinent information as needed.

Analyzing complaint data daily to identify possible areas for improvement for the department. Responding to complaints within a 14-day grace period in order to meet strict Health Insurance

Casework System (HICS) guidelines. Utilizing systems, such as PA250, MetaVance, NCompass, NCSW, HICS, and 834File to gather

research to resolve consumer complaints made through the Health Insurance Marketplace. Performing heavy volume data entry and analysis for Marketplace member’s under a large and

expanding state contract, while ensuring the data is entered correctly into multiple database systems.

Working as a lead on a project to execute quality assurance queries into over 900 member’s files so incorrect issues could be identified and resolved in order to reduce audit possibilities.

Communicating directly with members and insurance plans on a daily basis in order to resolve benefit and claim issues, while also addressing requests from multiple internal departments within BCBSM.

Formally notifying members by individualized letters explaining the changes that may have been made or may have occurred on their accounts, and when necessary offered an appeal to have an escalation filed.

Understanding and learning the billing portion of BCBSM to correctly explain billing errors or billing amounts incurred on member policies.

Assisting with training new hires for the Health Insurance Marketplace during open enrollment.

REFERRAL/PATIENT NAVIGATOR JUNE 2015 – OCTOBER 2015

Fidelis SecureCare – Detroit, MI

Helped execute and explain the MiHealth Link program to members who were eligible to receive both Medicaid and Medicare health care benefits.

Navigated and documented in various electronic health Systems (eClinical Works, SAMI, TruCare) to resolve patient and provider issues.

Worked closely with the Utilization Management Department to resolve continuity of care issues, while transitioning out-of-network patient’s into in-network providers.

Helped members get approved to remain with their out-of-network providers under the continuity of care rule.

Utilized Microsoft Excel to create reports sectioned off by districts, case coordinators, patient information, health risk assessment completed, and insurance enrollment dates.

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Processed patient referral’s using correct ICD-9 and ICD-10 codes in adjacent to the correct CPT codes so authorizations could be received in a timely manner by inpatient and outpatient facilities.

Conducted interviews with members to identify specific health needs through the use of initial risk screening questionnaires.

Worked within the community to help locate members that had not been able to be reached prior to open enrollment, and completed their required assessments and provided them with the necessary information to local area agencies and case coordinators.

Created administrative and care plans that allowed for case coordinators to efficiently and effectively determine the needs of the population the company was servicing.

LEAD MEDICAL RECORDS COORDINATOR AUGUST 2013 – MAY 2015

Western Wayne Family Health Centers – Inkster, MI

Maintained a full-time presence receiving, scanning, and managing electronic records. Prepared electronic patient charts for medical staff by scanning in all documents received via fax, email,

hard copy, etc. into the appropriate medical records file. Scheduled and conducted appointments for HEDIS Chart reviews for multiple insurance companies. Functioned as the troubleshooter with Vendors to resolve any issues/problems/concerns. Prepared outgoing electronic patient correspondence in accordance with HIPAA guidelines. Pulled correspondences, labs, results, consult reports, medical records, etc., and electronically attached

the files to the appropriate patient charts. Filed all paper charts upon completion of electronic scanning in a manner that allowed

easy methods of retrieving. Processed and responded to medical record requests for stored/archived files in a timely manner. Carefully reviewed medical records for accuracy and completion as required by insurance companies. Implemented new policies and procedures for handling medical records, while keeping the Medical

Records Department up to date with state and federal regulations. Generated patient invoices for records using excel and recorded all the invoices processed on a

spreadsheet. Worked with the LEAN Project partnered with BCBSM to develop strategies to create efficient clinic

practices. Presented a training based on the LEAN findings to the clinic on new processes and improvements

through the use and creation of PowerPoint slides.

FRONT DESK REPRESENTATIVE MAY 2012 – AUGUST 2013

Western Wayne Family Health Centers – Inkster, MI

Maintained the receptionist area, including greeting visitors and responding to in-person requests for information.

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Received patients, answered calls and queries, assisted patients in completing medical forms, and collected fees per clinic protocol.

Registered patients and informed them of the medical policies to be followed, and the services offered at the facility.

Scheduled patient appointments. Documented and organized patients' records for reference. Maintained front office supplies and the records of daily monetary transactions. Completed insurance verification with health-care providers, including Medicaid, Medicare, and PPO and

HMO servicers. Processed patient referral request. Thoroughly investigated past due invoices and helped to minimize the number of unpaid accounts. Directed patient flow and minimized patient wait time. Troubleshot and resolved issues in a quickly manner in a high volume medical call center.

CUSTOMER ASSISTANT REPRESENTATIVE MARCH 2008 – MAY 2012

Best Buy - Westland, MI Maintained a neat and well-presented store, while replenishing merchandise on a daily basis. Answered and directed phone calls to the appropriate departments. Built customer rapport through the process of understanding each customer’s own personal needs. Drove sales by increasing product sale’s baskets. Performed consultations with customers for Geek Squad services. Shared product knowledge with customers while making personal recommendations. Demonstrated that customers come first by serving them with a sense of urgency.

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