1. Nicole Houston
Nicolemiller00@yahoo.com Phone: 781-964-
9263
SUMMARY OF QUALIFICATIONS
Dedicated, effective leader with experience in the health care environment and expertise in customer service, claims
management, process improvement workflows. Proven ability to effectively lead staff, and collaborate with senior
leaders, customers and internal/external business partners to achieve defined departmental and corporate goals
that exceed performance expectations
PROFESSION EXPERIENCE
Blue Cross Blue Shield of Massachusetts
BLUECARD INTERPLAN HOME SERVICE REPRESENTATIVE Feb 2012-Present
· Collaborate on a daily basis with other Blues Plans for completion of many claims processing inquiries.
· Reviewed and resolved adjustments and informational requests from various internal areas such as Member
Service, Medicare Markets, Account Service, and Grievances.
· Resolved pending adjustments initiated and suspended for manual review by Provider Services, COB, TPL, to
ensure accurate third party processing.
· Processed adjustments using TPS, NASCO, TSO, EM, ITS, BlueServe Connect and BlueSquared.
· Researched and resolved inquiries received from a Priority Hotline working closely with leaders ensuring first call
resolutions.
· Initiated and resolved claim adjustments for Provider Audits, DRG Validation and Hospital Credit Balance
recoveries, and the Recovery Area providing support of company financials.
· Identified trends and opportunities for process improvements. Assisted management with implementation of
several updated workflows and job aides within department to improve internal processes and streamline
workflows.
· Investigated system discrepancies for resolution of issues claims processing issues pertaining to claim edits, system
flushes, system discrepancies, and benefit coding problems.
· Exhibited a spirit of teamwork and contributed ideas for division and company success. Received several awards
from fellow associates for going the extra mile.
· Trained over 10 new hire associates to be proficient in NASCO/ITS/BlueSquared and accurately and efficiently
research and adjust claims. Created workbooks for new associates to guide them through the learning process of
claims service.
· Managed all Union Blue account inquiries internal and external as point of contact. Responsible for daily inventory
management of Union Blue accounts.
· Developed strong working relationship with Union Blue accounts guaranteeing customer satisfaction for union
blue members. Ability to cross train peers on Union Blue matters as inventory requires
· Increase skill set by understanding and working Out of Balance Report (OOB) to correct financial errors. Identified
several claims processing errors and initiated RFR’s requesting system fixes by researched, financed, and
implemented.
MEDICARE MARKETS MEMBER SERVICE REPRESENTATIVE Jun 2011-Feb 2012
· Interim Supervisor leading a team of 8 call center associates responsible for external communication to Blue Cross
Blue Shield of Massachusetts members, ensuring consistency of operations, service delivery, and staff
management across the team.
· Researched and dispersed daily inventory of internal and external inquiries to associates.
· Proficiently skilled in Medicare Markets including Medicare Advantage, Medex, and Managed Blue for Seniors
which expanded job knowledge and supports other business areas.
· Consistently adheres to strict government rules relating to Center for Medicare processes.
· Partnered with leadership team as needed to ensure first call resolution and member satisfaction by participating
in several meetings on best business practices.
MEMBER SERVICE REPRESENTATIVE Aug 2008-June 2011

2. · Exceeded business expectations by maintaining excellent phone metrics and call quality by delivering and
diffusing difficult messages to members to prevent future call backs
· Supported several lines of business including National, Pharmacy, CDHP, Direct Pay, and Interplan which boosted
phone support to keep business area in line with department goals to reduced average speed of answer(ASA).
· Collaborated with Business Experts to reduce personal and team inventory to ensure first call resolution and
member satisfaction.
· Contributed to the success of over 30 new hire and seasoned associates by providing support with escalated calls,
assisting with side by side mentoring and answering general questions in a phone lab setting.
· Received multiple Member Impact awards due to delivering superior customer service.
· Assisted Managers with elevated issues, taking escalated member calls when necessary.
· Shared best practices by maintaining a daily awareness of business changes and updates.
Braintree Rehabilitation Hospital
MEDICAL SECRETARY Jan 2003-Aug 2008
· Established and implemented new organization process for patient appointments and trained staff on new
process.
· Coordinated appointments and transportation for 90 patients to ensure patients received the appropriate care
when needed. Contacted several ambulance companies daily for pick up of patients. Ensured correct type of
ambulance transported patient for their specific needs.
· Requested and maintained medical records to create and maintain patient charts which ensured patients were
receiving proper care. Followed appropriate HIPPA guidelines.
· Faxed and translated physician charts with speed and accuracy during code blue situations to appropriate hospital
receiving the patient.
· Collaborated with Doctors, Nurses, and Case management daily for complete patient care as well as
Communicated Doctors orders to pharmacy department via faxing and telephone.
PHYSICAL THERAPY AIDE February 2005-January 2006
· Facilitated several large exercise and cognitive groups of 15 or more patients 2-3 times a day teaching patients
proper muscle movement for safety and effectiveness as well as promoting brain function.
· Taught patients active daily living techniques which boosted patient recovery success as they were able to be
more independent.
· Teamed with Physical Therapist, Occupational Therapist, and Speech Therapist to create daily activities to promote
rehabilitation of all medical conditions.
· Assisted with patient care when low on staff to support nursing aides and nurses with bathing, clothing, and
feeding dependent patients.
NURSES AIDE Apr 2003-Feb 2005
· Provided exceptional patient care to short term and long term residents.
· Responsible for daily care including washing, dressing, feeding, and providing comfort for patients.
· Assisted Therapy department with patient transport safely and efficiently.
· Transported specimens to laboratory several times per day to ensure proper processing.
EDUCATION/BACKGROUND
Quincy College- Associate in Science Degree, In progress
World Wide Education- Certificate in Customer Service 1998
COMMUNITY SERVICE:
Received Spirit Award from BCBMSA-2014
United Way Drive- 2014
Cradles to Crayons Clothing Drive-2013
Franklin Park Coalition/Leader-2012
Special Olympics Falmouth Ma – 2011