Melanie Banks
FELTON
Summary
Results-driven healthcare operations professional with over 13 years of experience in health insurance, focusing on medical cost containment and project implementation. Expertise in out-of-network pricing, workflow optimization, and process redesign. Proven leader in managing customer service teams, enhancing member experience, and driving operational improvements. Currently pursuing a Digital Project Management certificate with training in Agile methodologies and Jira.
Overview
14
14
years of professional experience
1
1
Certification
Work History
Medical Cost Reduction Analyst
Horizon Blue Cross Blue Shield
Newark
03.2024 - Current
- Led an RPA automation initiative that reduced manual claim adjustments by 60%, improving accuracy and operational efficiency.
- Identified trends, root causes, and improvement opportunities using data-driven analysis to support MCR initiatives and claims accuracy goals.
- Supported implementation and monitoring of medical cost maximization initiatives, ensuring operational readiness through training, documentation updates, workflow validation, and staffing analysis.
- Championed change initiatives across the Service Division, enabling seamless adoption of new programs and system enhancements with minimal impact to member and provider experience.
- Assessed pending claim inventory and reviewed X12 278 EDI transactions to ensure accurate processing and early identification of service risks.
- Coordinated with external vendors to resolve complex out-of-network billing issues and pricing discrepancies, enhancing claim resolution processes.
- Partnered with IT, business owners, and SMEs to identify workflow impacts, support requirements development, and ensure alignment during project implementation and stabilization.
- Documented issues and facilitated root-cause analysis during post-production review cycles, ensuring timely resolution and accuracy of claim outcomes.
- Applied process improvement methodologies to enhance workflows, reduce rework, and strengthen operational controls.
Service Operations Team Lead
Horizon Blue Cross Blue Shield
Wall
08.2021 - 03.2024
- Supervised a cross functional team of 10+ agents in a high-volume contact center supporting correspondence, chat, phone, and email inquiries.
- Managed team workflows to ensure timely processing of member inquiries and requests.
- Monitored and reported KPIs including average handle time, speed to answer, quality scores, attendance, productivity, and backlog reduction to track team performance.
- Conducted regular one-on-one coaching, performance evaluations, and development planning to drive accountability and employee growth.
- Acted as an escalation point for member and provider calls involving complex billing, benefits, and access issues, complying with regulatory and organizational standards.
- Supported operational change initiatives and process improvements, enhancing member experience and minimizing service errors.
- Fostered a culture of service excellence and continuous improvement, aligning team practices with organizational values.
- Partnered with internal departments to develop response strategies for complex service and access issues.
- Facilitated regular team meetings to discuss performance, challenges, and solutions.
Dual Special Needs Program Clinical Care Coordinator
Horizon Blue Cross Blue Shield
Mt. Laurel
04.2019 - 08.2021
- Facilitated health care services within a member-centric plan of care.
- Utilized care management process to drive goal-directed member care and boost member engagement in the program.
- Mentored and coached team members on operational processes and care management best practices.
- Contributed to user acceptance testing and process improvement initiatives to optimize care management workflows.
Managed Care Coordinator II & I
Horizon Blue Cross Blue Shield
Mt. Laurel
06.2012 - 04.2019
- Handled high-volume inbound calls and processed authorization requests, ensuring accurate documentation and effective communication with providers and internal clinical teams to streamline operations.
- Maintained high standards of customer service and compliance, contributing to operational accuracy and enhancing stakeholder satisfaction.
- Resolved escalated phone and correspondence inquiries through effective information gathering and coordination.
- Responded promptly to provider inquiries regarding eligibility verification and managed care operations, facilitating timely resolutions and supporting care coordination.
- Led process improvements, including transitioning from fax-based to email-based clinical intake.
- Coached and onboarded new hires through virtual and in-person training.
- Achieved promotion to Coordinator II for demonstrating strong initiative and effective performance.
Education
Digital Project Management Certificate - true
Temple University
Online04-2026
Supervisory Skills -
Horizon University
01-2021
Pathways of Leadership -
Horizon University
01-2020
MBA - Healthcare Administration
Wilmington University
Wilmington, DE05-2019
Bachelor of Arts - Economics
Rutgers University
Camden, NJ05-2007
Skills
- Service operations leadership
- Team management
- Data analysis
- Change management
- Cross-functional collaboration
- Remote team leadership
- Claims processing and payments
- Microsoft Office Suite
- Tableau data visualization
- Care Radius software
- Multiplan/Zelis portals
- Root cause analysis
Certification
Atlassian Agile Project Management
Timeline
Medical Cost Reduction Analyst
Horizon Blue Cross Blue Shield
03.2024 - Current
Service Operations Team Lead
Horizon Blue Cross Blue Shield
08.2021 - 03.2024
Dual Special Needs Program Clinical Care Coordinator
Horizon Blue Cross Blue Shield
04.2019 - 08.2021
Managed Care Coordinator II & I
Horizon Blue Cross Blue Shield
06.2012 - 04.2019
Digital Project Management Certificate - true
Temple University
Supervisory Skills -
Horizon University
Pathways of Leadership -
Horizon University
MBA - Healthcare Administration
Wilmington University
Bachelor of Arts - Economics
Rutgers University