Crystal Phiri
Chelstone
Summary
Dynamic Claims Assessor with expertise in claims auditing and quality assurance. Proven ability to enhance compliance and resolve complex queries, ensuring efficient claims processing. Strong analytical thinking and customer service skills drive successful outcomes, fostering positive relationships with clients and stakeholders. Committed to delivering high-quality results in fast-paced environments.
Overview
7
7
years of professional experience
Work History
Claims Assessor
Continuum Zambia
08.2019 - 07.2023
- I have developed proficiency working with a world class health administration system (HIP) to process claims and ensure compliance to achieve the following key result areas in my current role:
- Conduct overview reconciliations with HCPs to ensure the claims submitted correspond with the statement.
- Continuously sustain claims quality assurance& claims auditing and analysis.
- Handling the claims repudiation process and resolve queries.
- Processing member refund claims and ensuring payment within the refund cycle.
- Ensuring that all relevant documents and claims are Indexed onto the system with the claims processing cycle.
- Ensuring that claims are stamped and officially received claims receipt.
- Allocating claims as per standard scheduling and payment cycle.
- Handling Document Management process and ensure the physical documents are scanned into the system.
- Pre-authorizing the optical and dental request in line with the standard benefit booking procedure.
- Claims Assessing – Assessing claims as per scheme rules, guidelines, process, and protocols with maximum accuracy and quality Assurance.
- Providing prompt and relevant feedback to clients and providers on the queries.
- Interacting with claimants and oversees the review of claim form.
- Processing authorizations for in-patient claims.
- Ensuring a minimum record of risks in claims processing (Risk identifying, assessment, controlling, monitoring and mitigation).
- Ensuring efficiency in claims management& record keeping.
- Establishing and maintaining of good relations with clients.
- Membership billing and underwriting (Disease disposition of the group& onboarding risk assessment).
- Compiling weekly work reports, drafting & minutes writing, and translating raw data into reports etc.
- Ability to deliver effective and high-quality tasks and results.
- Effective compliance to instruction and guidelines outlined.
- Attention to detail with accuracy and quality assurance.
- Competence in time management.
- Ability to offer collective action and teamwork.
- Efficient record keeping management.
- Attentiveness in responding to both internal and external queries.
- Ability to establish and maintain good relations with claimants.
- Quicker receptiveness/adaptation to change.
- Ability to compile reports, minutes and submit reports on time.
- Computer skilful e.g., Word, Excel, Power Point etc.
Connector
Young Women Christian Association
01.2017 - 12.2018
- Provide mentorship and supervision to mentors under you.
- Field work mainly to recruit the girls eligible for mentorship and assign girl groups to mentors under my supervision.
- Providing sex, & sexual diseases education to adolescent girls.
- Providing HIV Testing and Counselling services.
- Index testing services& case identification.
- Providing intensive adherence counselling& follow ups on girls on Art treatment in collaboration with local clinics.
- Family Planning education & service provision with the aid of local clinics.
- Providing and recommending clients for sexual transmitted disease treatment to local clinics e.g., cervical cancer screening, syphilis, chlamydia, warts, and others.
- Assessing vulnerability levels on girls in need of sponsorship.
- Recommending educational sponsorship for vulnerable girls identified.
- Providing child protection services &information to the local Police regarding sex or child defilement offenders.
- Providing Financial management education through village banking.
- Providing body development and changes education to adolescents.
- Data collection, Data Analysis and Data entry into two different Data Systems.
- Compiling weekly work reports, drafting & minutes writing, and translating raw data into reports etc.
- Effective compliance to instruction and guidelines outlined.
- Ability to identify & collect participants’ demographic data and entry on survey platform using tablets/laptops.
- Data Accuracy, Data Security and Data Collaboration with my team.
- Capability to identify participants for the Dreams Project.
- Ability to collect primary and secondary data and translate raw data into reports.
- Strong attention to detail and accuracy with quality assurance.
- Leadership skills.
- Capable of creating awareness on sexually transmitted diseases, adolescent body development, rape, child molestation and different lifestyle situations.
- Ability to manage and supervise mentors working under my obligation& to foster teamwork and collective action.
- Ability to adapt and handle change.
Internship
Ukadzipalile Integrated Projects
04.2015 - 12.2015
- Gathering helpful and necessary information regarding different projects or programs.
- Conducting interviews to participants.
- Identifying and recommending vulnerable people deserving empowerment.
- Training clients with different skills such as farming, poultry etc.
- Creating awareness on different life-threatening situations such as disease outbreaks and preventions.
- Ability to Collect, Analyse, Collaborate, and Document Confidential Data Set.
- Community sensitization skills on various issues like diseases, agriculture, gender-based violence, early marriages etc.
- Strong attention to detail and accuracy with quality assurance.
- Ability to create an efficient and friendly team.
Internship
Social Welfare Office Kafue District
12.2010 - 08.2011
- Prepare clients requirement files and maintain records.
- Preparing reports for meetings, juvenile offenders, and students bursary reports.
- Counselling (Juveniles on probation/ victims of defilement).
- Delivering letters and notifying stake holders when meetings are to hold.
- Scheduling appointments on behalf of the District Social Welfare Officer.
- Investigating clients seeking help to ensure that their request is genuine.
- Field work mainly to interview clients concerning their challenges, assessing clients’ vulnerabilities, and investigating various cases brought to the department of social welfare office.
- Self-confidence and ability to work without supervision.
- Capable of data collection& translation of raw data into reports.
- Ability to evaluate assistance and gauge the levels of vulnerability by either declining or approving requests& ability to compile minutes from meetings.
- Identify those in need and Help people of all life stages cope with and solve everyday problems.
- Advocate for and develop plans to improve clients’ well-being.
- Research and refer clients to community resources.
- Work with individuals, families or groups.
- Respond to clients in crisis situations.
- Work in a variety of public and private organizations.
- Observe client behaviour, assess needs and create treatment strategies.
- Diagnose psychological, behavioural and emotional disorders.
- Develop and put treatment plans in place.
- Consult with doctors, therapists and medical professionals.
- Administer social service programs and Instruct clients’ families during treatment.
Education
B.A. - Development Studies with Public Administration
University of Zambia
05-2022
Diploma - Social Work
Evelyn Hone College of Applied Arts And Commerce
08-2012
Grade 12 Certificate -
Naboye High School
12-2007
Skills
Customer service and support
- Verbal and written communication
- Problem solving
- Database management
- Analytical thinking
- Decision making
- Research skills
- Project management
- Data analysis
- Claims assessment
- Quality assurance
- Compliance management
- Case review
- Fraud detection
- Expense management
- Coverage analysis
- Coding systems
- Documentation review
- Policy interpretation
- Professional ethics
- Financial acumen
- Claims auditing
- Customer relationship management
- Adaptability and flexibility
- Workload prioritization
Accomplishments
- Developed a new shortfall record report that helped in recovering the company’s money, reducing shortfalls by 48%, to over 85 customer calls daily, and solving 90% of their concerns
- Designed a customer service report document while harnessing my high emotional intelligence (EQ)
References
- Mr Raymond Kufekisa, Chief Executive Officer, Continuum Zambia Limited, Lusaka, +260 969 860 603
- Mrs. Mwamba Katebe, N’gombe Dreams Supervisor, Young Women Christian Association, Lusaka, +260 973 228 881
- Mr Martin Kafula Daka, Project Manager, Ukadzipalile Integrated Projects, Lusaka, +260 976 017 234
Timeline
Claims Assessor
Continuum Zambia
08.2019 - 07.2023
Connector
Young Women Christian Association
01.2017 - 12.2018
Internship
Ukadzipalile Integrated Projects
04.2015 - 12.2015
Internship
Social Welfare Office Kafue District
12.2010 - 08.2011
B.A. - Development Studies with Public Administration
University of Zambia
Diploma - Social Work
Evelyn Hone College of Applied Arts And Commerce
Grade 12 Certificate -
Naboye High School
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