Customer Service Services Representative
Resume:
PROFESSIONAL SUMMARY
Seasoned Provider Services Representative also assisted in Member
Services department with a robust background in insurance verification and HIPAA compliance, honed at Common Wealth Care Alliance. Excelled in relationship building, leveraging Salesforce CRM expertise to enhance provider experiences and streamline claims processes. Proven track record in resolving complex issues, demonstrating exceptional communication skills and empathy. SKILLS
• Insurance verification • HIPAA compliance
• Data entry proficiency • Relationship building
• Computer literacy • Salesforce CRM
Healthcare industry
knowledge
• • Problem-solving abilities
• Call center experience Medicare and Medicaid
knowledge
•
• Compliance management • Conflict resolution
• Excellent communication • Call Documentation
• De-Escalation Techniques Billing Adjustments and Refunds
•
• Customer Service • Empathy and understanding
• Microsoft Office proficiency
CONTACT
wallstreet-
ad5dyy@r.postjobfree.com
EXPERIENCE
Provider Services Representative
MAY 2019 - DEC 2023 Common Wealth Care Alliance, Boston Assist providers with processing override for pharmacy rejections, obtain verbal approval from Prescribing doctors to override controlled substance prescription drugs
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• Provide eligibility effective date & benefits, confirm if there's oop, copay, deductible, coinsurance, group numbers
• Use defined standards and instruction manuals to process claims accurately and completely
• Reviewed the provider contracts, paid members claims, based on the CPT code & ICD-9 that were submitted ARNOLD EDEN
Claims Services Representative
SEP 2018 - MAR 2019 Beacon Health Options, Woburn Facility Management Customer Service
SEP 2017 - FEB 2018 Aerotek
Bilingual (Spanish) Customer Service Representative OCT 2016 - FEB 2017 Panther Group/ Maximus
Cash Processor
APR 2016 - JUN 2017 Account Temps
• Review authorization status of pending authorizations
• Submit activities to Utilization Management department to update approval letters. Confirmed national provider identifier numbers, confirmed to provider if there in network or out of network, document out of network provider information
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• Utilize Salesforce tool to document calls
• Utilize panviva tool CCA medical plan benefits and educational updates with plan.
• Handling incoming & outbound calls from Providers related to claim processing issues and the reporting of losses
• Explaining rejected claims, manually submitted claims, follow up with iht tool for cpt code errors
• Ensure claim files are properly documented and claims coding is correct
• Warm transfer members requesting behavioral advise to a behavioral health specialist.
• Duties were to: Facility Management, Business Administration, Construction Management, Security
• Proficient with Microsoft Office Suite of software including Word, Excel, and PowerPoint
• Input and management of incoming incidents and work
• Order requests including follow through utilizing multiple tracking systems
• Create facility work orders, cancel work orders, assign and reassign work orders Dispatch work orders to technicians, provide work order numbers, store numbers, address, descrption, notate details of work confirmation after dispatching
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Report to regional field managers on a regular basis (daily/weekly/monthly) on conditions relative to general operations, assigned tasks, and day to day activities, escalations to resolve work orders that have.
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Duties were to: Respond accurately to Primary Care Physician calls related to status changes, transportation guidelines, member eligibility/managed care status, prior authorization, and pharmacy guidelines/procedures
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Provide members with all current healthcare options available to promote member choice within the assigned network or managed care providers, using knowledge gained through training and other sources
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Complete all related paperwork and necessary forms including enrollment forms, member requests and personal reimbursement within established timeframes and guidelines
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• Investigate all third party resources and comply with systems and administrative requirements Facilitate the resolution of non-clerical issues related to client and provider compliance/participation according to established policy and protocols
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• Perform accurately all data entry function to reflect member or provider activity/transactions
• Conduct all interactions with members and providers in a discreet, courteous and professional manner.
• Duties were to: Process, verify and balance inbound and outbound liability
• Complete data entry for all transactions of liability Bilingual (Spanish) Customer Service Representative SEP 2012 - AUG 2016 Guardian Interlock
• Prepare outbound orders and replenishments for the next day's routes
• Count, verify and report every item in inventory daily. Duties were to: Ensure that each customer receives outstanding services by providing a friendly environment which includes greeting, and acknowledge every customer maintaining outstanding standards solid product knowledge and all other aspect of customer service
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Responsible for maintaining outstanding customer service as per company standard, processing sales quickly, accurately and efficiently
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Recommends potential products or services to management by collecting customer information and analyzing customer needs
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Assist client over the phone with request such as appointment information, rescheduling existing clients, and FAQ about the ignition interlock device
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Opens customer accounts by recording account information including troubleshooting clients who are in need of assistance with their interlock devices
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• Take payment information and other pertinent information such as addresses and phone numbers. EDUCATION
High School Diploma
OCT 2008 Continental Academy
Completed coursework towards Computer program
US Atlanta Technical College
LANGUAGES
Spanish
Native
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BRIEF DESCRIPTION
Results oriented, with a proven record of accomplishment for sales excellence, customer satisfaction, managing profitable relationships, improving work-flow processes. Recognized for achievement and performance, ability to think and act quickly to resolve problems and maximize profits. Numerous accolades in Customer Service. Extensive Systems Knowledge. Proficient in Microsoft Office/Internet.
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