Kristyn Ross

Kristyn Ross-| - | Calumet City, IL | www.linkedin.com/in/kristynaross SUMMARY Accomplished customer service professional with over a decade of experience in the financial, retail and insurance sectors. Proven track record in leadership, data analysis, processing, administration, project management and conflict resolution. Adept at navigating complex inquiries, improving client satisfaction, and ensuring adherence to compliance standards. A dedicated team leader, recognized for optimizing service processes driving customer and client loyalty. SKILLS Technical proficiency, Empathy, Interdepartmental and Stakeholder collaborations, ADP, Workday, ICD-10, HCPCS, CRM/EMR/ECMS/SAP/ERP software, Excel VLOOKUP/XML/PivotTables, STD, LTD, FMLA and WC WORK EXPERIENCE NTT Data Services -Harvard Pilgrim HealthcarePlano, TX Claims Management SpecialistMar 2024 – Sept 2024 Claims Process Optimization; improved claim handling processes to enhance efficiency implementing technology driven results resulting in reduced processing time. Complex Claims Processing and Resolution: handled high -value, complex and sensitive claims applying advanced knowledge to investigate, evaluate, process and resolve claims within legal and regulatory requirements. Evaluate medical claims and coordinating preauthorization requests for compliance with coding standards and adherence to clinical guidelines, ensuring precise reimbursement criteria are met via EPIC and HER. Vendor and Third-Party Management; managed relationships with third-party vendors, such as appraisal services and investigators ensuring effective collaboration and cost efficiency in claims processes. Tailored Management -Cardinal HealthColumbus, OH Case Management ConsultantNov 2023 - Dec 2023 Care Coordination and Advocacy; Acted as a liaison between clients, healthcare providers and insurance carriers to facilitate access to services and continuity of care for medical and behavioral health prescriptions. Risk Assessment and Crisis; Identified high-risk situations intervening when necessary to de-escalate crisis. Resolved complex payer and pharmacy issues by utilizing negotiation and problem-solving techniques, maintaining compliance with company policies and PHI protocols. Manage SOPs to reflect accurate directives APN Software Services -Franciscan HealthNewark, CA Account ManagerJul 2023 - Sep 2023 Client relationship management: built and maintained relationships with key healthcare providers and clients acting as a trusted advisor to address their needs, resolve issues and support long-term goals. Client Education and Empowerment; Coordinated the integration of new patients ensuring they were well prepared to utilize all services effectively. Program development and improvement; Oversaw the establishment of patient portal accounts to streamline the management of health records and the scheduling of medical appointments. AT&TChicago, IL Customer Success and Retention StrategistJun 2022 - Jun 2023 Customer Experience enhancement; identified pain points in customers journey and collaborated with cross functional teams to improve service, delivery and product offering. High-Value Account management; handled at risk accounts providing tailored solutions to address unique concerns to keep customers engaged with services. Customer retention strategy development: implemented personalized retention strategies to reduce churn, improve loyalty and increase lifetime value. GoHealth Inc.Chicago, IL Licensed Insurance AgentApr 2021 - May 2022 Licensed in 35 states to write Aetna, Cigna, Anthem, Humana, United Health, Kaiser Permanente, and Centene policies. Client consultation and needs assessment; provided tailored advice on insurance plans based on the client’s healthcare needs and history. Policy design and customization; customized insurance packages, educating on all available options, coverage levels and terms in detail ensuring the best-informed decision was made. Regulatory compliance and industry expertise; maintained up to date knowledge on health insurance regulations, industry standards and compliances with relevant laws. Sedgwick Claims Management SystemsChicago, IL LTD, STD, FMLA and WC Claims ProcessorFeb 2020 - Mar 2021 Claims investigations and verification; processed short-term disability, long-term disability workers, family medical leave of absence and compensation claims in compliance with state and federal WC laws and industry regulations mitigating legal risks. Complex case evaluation; managed high-value workers compensation claims, short term and long-term disability claims, assessing injury details, evaluating medial documentation and determining eligibility and appropriate compensation. Return to work planning; worked closely with employers, medical providers and employees to develop effective return to work scheduling balancing the needs of the employee and the organization. Kforce -Northwestern MedicineChicago, IL Claims Financial AssessorAug 2018 - Feb 2020 Complex claims evaluation: reviewed and processed high-value medical claims for denials that require advanced knowledge of healthcare policies, coding and reimbursement guidelines to ensure accuracy. Risk assessment; processed and finalized high dollar claim denials in preparation for tax reporting. Land of Lincoln HealthChicago, IL Senior Benefits and Claims Coordinator SupervisorDec 2015 - Jun 2018 Leadership; managed a team of 12 colleagues, focusing on operational efficiency and staff training to enhance overall service quality. Project management; executed process enhancements to elevate service standards for members and providers, ensuring alignment with industry and company benchmarks. Complex claims evaluation: processed and audited high-value and complex medical claims that require advanced knowledge of healthcare policies, coding and reimbursement guidelines to ensure accuracy. Reviewed and processed appeals and reconsiderations in accordance with Medicare NCD & LCD guidelines, aiding in equitable and informed resolution of claims. Blue Cross and Blue Shield of IllinoisNaperville, IL Benefits, Claims and Membership Customer Advocate SpecialistJan 2014 - Dec 2015 Claims escalation and issue resolution; managed escalated claim issues and reprocessed claims as needed. Policy and benefits Consultation; educated clients on their coverage options guiding them toward optimal use of their benefits. Appeals escalation and resolution; processed appeals and reconsiderations in accordance with Medicare NCD & LCD guidelines, along with state and federal WC laws aiding in equitable and informed resolution of claims. Facilitated the transition of retail department applications to an electronic format, enhancing data accuracy and system reliability. MaximusChicago, IL Medicaid Eligibility SupervisorNov 2010 - Dec 2013 Leadership; managed a team of 8 colleagues, focusing on mentorship for performance improvements. Complex eligibility assessment: applied in depth knowledge of Medicaid regulations and policies to accurately determine clients’ available benefits. Mentor team members for performance improvements Case management and follow-up; managed a case load of applicants providing ongoing support to ensure timely completion of enrollment. High-level case resolution: addressed escalated and disputed cases investigating denials for falsely reported income and submitted documentation. Enhanced call center efficiency by examining call patterns and resolving customer concerns, leading to the establishment of a performance-based incentive system. EDUCATION Chicago International Charter School- Longwood CampusChicago, IL HS Diploma Jun 2004