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Click here or scroll down to respond to this candidateCandidate's Name
Tempe, Arizona Cell Phone: PHONE NUMBER AVAILABLE Email:EMAIL AVAILABLE(Texting is available)Objective:The next chapter in life to is find employment with a company who will recognize and utilize my educational background, knowledge and desire to succeed.Core Skills10+ Years working in the Administration Division of the Healthcare Industry15+ Years of Consumer Customer Support, Data Entry & Handling Patients RecordsProficient with Microsoft Operating Systems (Including Word, Excel, Outlook & PowerPoint)Experienced in software such as FACETs, Citrix Receiver, DMS, Hippa Gateway, Tri-wiki & SalesforceKnowledge of ICD-9, ICD-10 & CPT CodingTrained in Enrolling Customers into new, re-enrolling and making adjustments to existing plans.Team Coaching, New Hire Training & MentoringStrong Administration and Clerical backgroundAbility to Multi-Task with Multiple Screens, Systems and ApplicationsStrong typing and computer skillsProcess and Procedure Implementation knowledge and experienceKnowledgeable of the RX Claim/DOS SystemEntrepreneurWork At Home ExperienceTeam Lead, Escalation and Supervisor Training/SupportExceptional Customer Service CommunicationEMPLOYMENT HISTORYCigna HealthcareGrievance CoordinatorSeptember 2022-Present100% Remote positionGather, analyze and report verbal and written member and provider complaints, grievances.Prepare response letters for member and provider complaints.Maintain files on individual grievances and coordinate with other departments to resolve complex customer complaints.Manage large volumes of documents including copying, faxing and scanning incoming mail.Assist with HEDIS production functions including data entry, making calls to customers, provider's offices, and claims research.Aetna/CVS Health CareECA Encounter Claims Analyst / Team Lead September 2021 August 2022Remote Position as a Claims AnalystResearch and Resolve Encounter errorsReview and Adjust complex, sensitive and/or specialized claims in accordance with claim processing guidelines and desktop proceduresEnsure all compliance requirements are satisfied and that all payments are made against company practices and proceduresIdentify and report possible claim over payments, underpayments and any other irregularities.Facilitated Team Meetings, Schedules and adequate coverageMaintained individual and Team Goals by driving Monthly KPIs and MetricsMedix StaffingBright Health Care Insurance (Temp Position) Jan. 2021 to June 2021Enrollment SpecialistRemote PositionAssisted Members via Inbound Calls with their enrollment needsTroubleshooting Issues with BillingProcessed RefundsTook Payments via credit cardMaintain required KPI and Quality Assurance expectationsExperience in Drop Box, Zoom, Remote Desktop, Net Extender, Genelco OH for Billing and Enrollment & EMDIGlobal Nephrology, Southwest Kidney Institute Feb. 2020 to July 2020 ** During COVID19, the administrative side of the office was sent home to work remotely. When it was time to return to the office this position was eliminated due to head count reduction that was necessary for space separation when returning to the office. **Referral CoordinatorResponsible for contacting primary care physicians and insurance carriers to verify if referrals were needed for patient servicesDeveloped and Implemented a new process to streamline and efficiently improve the department productivityIncreased workload and productivity by 60%Used a Excel spreadsheet to track and match patient recordsSending out Fax requests to doctors offices to obtain referrals for patients visitsMade outbound calls to other healthcare facilities requesting referrals if not receivedData Entry into the Athena software to maintain and update patient recordsAttached referrals to patients appointment record for claim adjudicationFilled in as Standing Supervisors and provided other team members with backing and/or questionsVerified Insurance Policies and patient benefitsWorked as a Team Member to insure peak productivityConducted Training and provided mentor guidance for new team members/staffTemporary Positions/Assignments: June 2019 to February 2020The temporary positions below were set up and managed by a Staffing Agency.McKessonCase ManagerBenefits InvestigationsVerify Insurance eligibility via payer websites, portals and phonesRecognizing and determining various types of insurance, Commercial, PPO, Medicaid & Medicare and their requirements for each and the current company policyEnsure that demographic and other information is correct and accurate in the patient database.I have thorough knowledge of ICD 10 and CPT CodesExperience in Merck Access program, handling specialty medications like Keytruda and LucentisMaking outbound calls to obtain information from the verifying eligibility for medication based on the patents insurance information planObtaining prior authorization for servicesGenerating benefits summariesObtaining deductibles and out of pocket informationProcurement of specialist referrals and verifying PCP (Primary Care Physicians) informationChecking that Medicare guidelines are being followed with the NCCN (National Comprehensive Cancer Network)Trained on various different drugs and related information pertaining to the protocols for that certain drug as it may differCVS Specialty PharmacyBenefits Verification June 2019 to Sept. 2019Verified benefits for adjudication of specialty claims.Monitored and Assigned claims via email and fax queues.Initiated pre-authorization for members medicationAssisted Members with financial help for high cost medication.Worked solely with insurance companies and doctor's office. Little to no interaction with actual members.Daily Quota Requirements: Maintain (touched) 16 - 19 cases and closed 8 dailyHumana, Inc (Call Center Facility) Tempe, AZNMI Member (Need More Information Team) (1 Year +) Nov. 2016 to Jan. 2019Responsible for managing and processing Front End AppealsCollected missing data from medical offices to complete authorizationsDealing with HMOs, PPOs and Medi-CareMentored new team membersOrganized team meetingsSME (Subject Matter Expert) Responsibilities included but not limited too organizing team workloads and mentoring new hires first two weeks on the floorJoined Humanas Safety Team as Floor Warden (exit strategies, First Aid, CPR & AED TrainingLead Team building activitiesAssisted Members with payments via credit card, checks and western union methodsProficient Communication and Written Skills required to communicate withQuick Learner and ability to adapt to changes and implement new proceduresHCPR (Humana Clinical Pharmacy Review) (1 years)Responsible for initiating and completing prior authorizations for non-formulary medicationsInputting data into systems such as Salesforce,Communicating with members via phone and emailReceive, document and resolve customer inquiries by using established best practicesEducate and inform customers, providers and employers about Humanas products and services via phone and emailInteract with Physicians office, Members, Long Term Care Facilities and HospitalsPrioritize daily tasks in order to maximize time and efficiently maintain all required workload each shift.Additional daily duties can include: Process referrals, pre-authorizationDaily workload consisted of 80 to 100 authorizationsK-Force Oct. 2015 to Oct. 2016As an employee of K-Force Staffing Agency, I completed two temporary assignments as they are described below:Trizetto (Call Center Facility)Claim Processor Feb. 2016 to Oct. 2016Responsible for examining and processing claimsFollow the approval and denial guidelines set forth by the state of New Jersey.Additional daily duties can include: Process referrals, pre-authorization, XC Claims, penny logic, ABD claims, warning messages, error codes and COBsMaintain weekly quota of 100+ claimsMedImpact (Call Center Facility) Tempe, AZCSR Pharmacy Benefits Helpdesk Oct. 2015 to Feb. 2016Responsible for handling all member calls related to prescriptions and medical plansResponsible for working with pharmacy to verify benefitsAuthority to adjudicating member insurance claimsAnswering an Avg of 80-100 call dailyCommunicating with helpdesk and PA desk using task routingSet up Premium PaymentsPayPal, Inc. (Call Center Facility) Chandler, AZClaims and Dispute Processor Jan. 2014 to March 2015Responsible for handling all disputes and claims for online purchasesAuthority to awarding or denying specific dollar amount depending on the situationAllowed to manage the decision of providing courtesy credit to customersAnswering an Avg of 50-70 call dailyMonitor and Process email volume for disputes and claimsProvide technical support for Customer accounts (password reset, online purchases, etc)Set up Payments and verify customer securityHandle customer bank accounts, credit card and debit card transactionParticipated as the lead speaker during team stand up meetingsAerotek/Catamaran (Call Center Facility) Tempe, AZMember Service Representative (10 month Assignment) March 2013 to Dec. 2013Receive inbound calls for PBM (Pharmacy Benefits Manager)Assisted Members with ordering refillsTroubleshooting for company websiteData Input into members recordCall Routing to correct departmentsLogged Customer ComplaintsUtilized the RX Claim/DOS System for all client inquiriesEducational Background : GED 1998 - Some college credit via Mesa Community CollegeReferences available upon request |
