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Click here or scroll down to respond to this candidateCandidate's Name
Tampa, FL Street Address Phone: PHONE NUMBER AVAILABLEEMAIL AVAILABLEProfessional Summary:Dedicated professional having experience more than 8+ Years into Customer Service and Healthcare.Worked Special projects SNP population (Medicare, Medicaid recipients) completing MDATs and HRAs. Engaged in self-development and training programs. Took pride in the De-escalation of irate calls ensuring member satisfaction and full utilization of insureds coverage.Assisted with enrolment for Medicare eligible customers into Medicare Advantage and supplement policies.I have a strong background in customer query handling and responded to incoming calls, e-emails and taking Inbound calls and Faxes.Proficient in Microsoft Office Suite (PowerPoint, Excel, Word, Access).Working knowledge of medical terminology and is available to join immediately, if offered.Understanding of healthcare quality measures (i.e., HEDIS, CAHPS, STARS, CMS etc.)SKILLS & ABILITIESStrong analytical skills able to evaluate claims and operational issues.Excellent ability to build and maintain business relationships with clients by providing prompt and accurate response within SLA.Excellent interpersonal skills able to work within a team.Excellent written and verbal communication skills geared to a customer focused culture.Microsoft Office Suite (PowerPoint, Excel, Word, Access).Experienced in operating/ managing data via, AS400, Verint, CRM, Workday, Salesforce, FLIMMIS, and EHDL, CAS, SharePoint).Leader in Inclusion and diversity within the organization.HUMANA - Clinical Claim Representative 2 11/2017-CurrentManaged queues and processed retro claims via MHK disputes. Managed claims via CAS, CGX, and CRMRegularly exercised discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes, and techniquesWorked under limited guidance organizing and prioritizing my day to insure correct handle and process of claims in a timely mannerManaged intake on Prior authorizations updated claim status and informed providers on steps for services requested while proficiently communicating Authorization determination and status updates and utilized electronic medical records and documentation programs.Proficiently navigated insurance portals and forms, while exercising a strong understanding of medical terminology and treatment proceduresVerified insurance coverage and benefits to determine eligibility for services, collaborated with other departments to follow the life of a claim/ authorization and ensure timely and appropriate care for members.HUMANA at Home- Referral Specialist 06/2016-11/2017Responsible for reaching seniors and disabled members in DSNP population, documenting questions, and concerns. Directing member to correct departments within Humana.Explained the full role and underlined the value of Care Management through (Humana) insurance carrier. Ensured that members received appropriate follow-up care.Worked Special projects SNP population (Medicare, Medicaid recipients) completing MDATs and HRAs. Engaged in self-development and training programs. Took pride in the De-escalation of irate calls ensuring member satisfaction and full utilization of insureds coverage.Managed daily call queue and Volumes, answered general questions and assisted with routing callers to the correct agent.College Hunks Hauling Junk and Moving Sales Agent 03/2016-06/2016Answered inquiries by clarifying desired information, researching, locating, and providing information.Demonstrated an unwavering commitment to customer service, adding new customers while maintaining premium service levels with existing accounts.Surpassed sales goals by maintaining a 96% booking rate and earning recognition for top sales.Healthplan ONE- Tampa, FL Customer Service Representative 10/2015-12/2015Assisted with enrollment for Medicare eligible customers into Medicare Advantage and supplement policies.Assisted members with questions concerning eligibility, claims, general coverage questions, and any questions or concerns about their health and prescription drug benefits with Harvard Pilgrim Medicare Advantage and Supplemental plans.Documented records of customer interactions or transactions, recording details of inquiries, complaints, or comments, as well as actions taken.Healthplan Services-Tampa, FL Recon Processor 10/2014-12/2015Measured and analyzed discrepancies identified from enrollment/eligibility files (834 transactions) and payment files (820 transactions) to outline/initiate improvements and ensure control of the processing gaps.Navigated enter data in the computer in a timely and efficient manner.Analyzed daily summary reporting of processed enrollment transactions received from the Exchanges to identify discrepancies.Assisted in interacted effectively with clients, listened carefully to their problems, and provided empathetic assistant while filtering and assigning member and provider escalation for research in obtaining the resolution for concerns.EDUCATIONHillsborough Community College - Tampa, FL 01/2012-1/2014Brewster Technical School - Tampa FL l Diploma 006/2011 |
