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Click here or scroll down to respond to this candidateCandidate's Name
Street Address Candidate's Name @gmail,com PHONE NUMBER AVAILABLESummaryHighly personable professional with several years of extensive experience in the pharmacy benefits management industry. My experience includes providing great customer service, supervising personnel, account management and claims data analysis. In addition to developing and cultivating relationships with various clients to conduct business and resolve issues in order to provide quality service.ExperienceClaims Technical AnalystPrime TherapeuticsDecember 2012 Present) Omaha, NebraskaI am currently responsible for providing subject matter expertise related to pharmacy claims processing. Leveraged knowledge of pharmacy claims data, adjudication logic, claims reporting, and experience with complex problem solving in order to support ongoing and project work related to Commercial and Medicare lines of business.Functional subject matter expert for claim processing system changes. Ensuring business requirements are complete and correct. Working with cross-functional teams to ensure that claims adjudicate according to business requirements by creating user acceptance and regression testing scenariosAssess the impact of claim processing system defects or setup errors. Provide leadership in performing detailed claims impact analysis.Research and provide insight into existing claim adjudication system functionality or claim processing outcomes.Facilitate collection of reporting requirements and create standard or customized reports via SAS or ad hoc query tool.Participate in training to keep claims processing knowledge up to date and assist with training and mentoring new hires.Run audit assistance related to claims data requests and other duties as assigned.Administer, balance and authorize payment of HMO claims.Conduct investigations to adjudicate claim/error reports and initiate adjustments for claims.Evaluate appealed claims and make necessary adjustments to establish proper benefit administration.Determine eligibility for manual claims and run vendor and internal error reports.Account SpecialistPrime TherapeuticsOctober 2006 December 2012 (6 years, 2 months) Omaha, NebraskaI was responsible for researching escalated issues, communicating with members and clients, and providing administrative support. In addition to meeting established service levels, member expectations and supporting implementations.Provided clients, members and pharmacies (Government Programs) with information regarding benefit plans to assure accurate claims processing and client/member satisfaction researchUtilized Primes internal systems to reply to questions and escalated issues from Primes internal and external partners in a timely manner and escalated issues as appropriateCommunicated issue resolution results per standard operating procedures in a timely mannerServed as a subject matter expert (SME) and mentor, assisting with technical questions, workflow or process directionCollaborated with the supervisor to identify process and/or quality improvement opportunities and assist in the implementation of solutionsAssisted leadership with various projects as the need aroseCollaborated with and responded to external clients and prepared / completed client reports as needed.I was chosen to handle High Priority groups as a direct contact to insure business continuityTraveled to North Carolina and Florida to assist with initial implementationSenior Service Agent: Seasonal PositionsPrime TherapeuticsSeptember 2004 October 2006 (2 years 1 month) Omaha, NebraskaIn my position as a Senior Service Agent I was selected to fill multiple seasonal roles to assist with the workload during peak season. I was also chosen to supervise personnel on several special projects to assist with Primes business needs.Paper Claims Supervisor Supervised small team of agents to who assisted with processing and reviewing Medicare paper claimsResolution Specialist Worked on dedicated call line taking escalated calls from Prime members to resolve their issuesPharmacy Agent I was responsible for providing pharmacies with information regarding benefits plan (co-payment, deductible, quantity and day supply limitations and assisting with claim adjudication.Research Specialist Handled and resolved memberSenior Service AgentPrime TherapeuticsSeptember 2003 September 2004 (1 year) Omaha, NebraskaI was responsible for supporting the Member Service Agents by taking escalated calls from Prime members that needed special handling to complete benefit inquires.Acted as backup for inquires that cannot be resolved by Member Service Agents and escalate issues that cant be resolved.Maintained knowledge of multi-channel process to include plan benefit information, phone and computer databases and customer service skills.Coordinated with other departments (Pharmacy Operations, Benefit Plans, etc.) for further investigation and resolution of inquiries.complaints by phone or written correspondenceMember Service AgentPrime TherapeuticsDecember 2003 September 2003 (8 months) Omaha, NebraskaI was responsible for handling incoming calls in accordance with department standards and other verbal and written training memorandums. I provided this service with a positive and proactive approach to ensure that the member issues were resolved the first time in a professional and caring manner within a Contact Call Center environment.Cultivated customer trust by providing members and pharmacies with accurate information regarding benefit plans to assure member and client satisfaction and accurate claims processingInvestigated and resolved phone inquiries in a timely manner and also forwarded escalated calls as needed to Senior Service Agents or SupervisorsProcessed member pharmacy refill requests, prescription renewals and placed outbound calls as needed regarding member benefits while maintaining professional and courteous communication resulting in high call qualityEducation & CertificationInstitute of Computer Science Omaha, NebraskaCertificate of Completion in Computer Applications1983 1985Northwest High School Omaha, NebraskaCollege Prep Studies1978 1982TrainingAdvanced Courses in Microsoft Excel 2003, PowerPoint 2003 and Outlook 2003Medical TerminologyConflict Resolution CourseTime Management and Prioritizing CourseLotus NotesAS400Ad Hoc QueryInterests/MembershipsChild and Family Development Corporation MemberBoys & Girls Club Omaha, NE VolunteerGirls Inc. Omaha, NE - VolunteerUnited Way Committee Prime RepresentativePrime Walk to Wellness Participant |
