Customer Service Medical

Functional Resume

Tamishia Clayborn Tamishia Clayborn 7870 Locher Way #24 Citrus Heights, CA 95610 916-***-**** ***********@*****.***************** SummarySuccessful results driven senior insurance operations executive offering over 16 years of experience in the insurance industry,operational growth, maintaining business structure, maximizing business opportunities, and ensuring compliance with regulatoryinsurance requirements. Genuine talent in building trust relationships in written and verbal communication across all age groups andlevels of an organization. Excellent leadership qualifications, customer relationship management/follow through, and employeetraining/supervision. Sincere with a client-focused approach that generates trust and allegiance. -Operations & General Management -Team Building & Leadership -Marketing & Business Development -Professional & Personable Attitude -Customer Care & Service -Rapport Building -Strategic Planning & Operational Budgeting -Skilled Multi-tasking Ability -General Operations & Productivity Improvement -Insurance Claims Ops./PBM/PHM ExpertiseExperience HighlightsCommunications & Customer Service Served as a Implementation Manager and Claims Development Specialist. Managed daily customer relationship development and establishment through direct contact to warm/cold leads. Influenced performance expectations through increasing client base by over 80% of the original client volume. Maintained customer service relationships and response to product inquiry/review Established development of new client relationships through customer satisfaction analysis. Maintained accurate records of new clientele interest and sales ratios per appointment Maintained general office relations and trained staff in customer service and new customer relationship development techniques. Developed marketing strategies and communication techniques specific to generating and maintaining customer interest. Addressed Chief Executive Officers while conducting face to face presentations related to benefit program implementation processes and management consulting servicesHuman Relations Management Facilitated training and development of staff in insurance claims development and implementation management. Instructed new associates on how to conduct face to face meetings and conference calls. Supported new associates in the development of claims development research and client/provider correspondences Conducted meetings related to staff communication and development. Encouraged staff and new associates to work as a team and support each-other through team building exercises Motivated associates to create and develop new techniques toward furthering the interest of clients to pursue further options to increase client interest in the products and services we were developing/implementingManagement & Supervision Supervised and organized the daily tasks of employees and encouraged team development while delegating tasks toward the execution and completion of projects. Produced consistent written and verbal communication between clients, members, and corporate associates. Administered the implementation process from the initiation of the agreement to the launch of the benefit/product purchased by the client 1 Tamishia Clayborn Maintained detailed records and developed client communication throughout the implementation process. Executed reporting and records for daily accounts payable and accounts receivable transactions between the client and contracted pharmacies. Lead cost reduction and process improvement projects resulting in improvement in department operations Managed daily overview of medical insurance claim submissions of workers compensation cases and health insurance claims through review of medical necessity of services rendered. Determined financial responsibility and accounts receivable/payable of services approved. Manual data processing and accuracy review of medical claimsPlanning & Research Analyzed and compared incoming data files and advised how to develop data according to specific formatting requirements. Gathered documents and distributed reports based on data analysis of medical files. Inspected medical claims data based on procedure and ICD-9/ICD-10 coding requirements. Determined medical necessity of injuries through face to face and telephone recorded statements. Researched and reviewed historical medical files and reports to verify medical necessity of services rendered to patients. Evaluated data related to business development projects and developed reports to explore the analysis of the business. Created business to business presentations and coordinated/managed the development of business implementation projects.Additional Skills MS Office, Lotus Notes, Outlook, Gmail, internet, and other propriety programs Analytical and payment accuracy review of medical files, forms, claims Medical coding/claim form knowledge, ICD-9 coding, HCPC/CPT coding, UB92/UB04/HCFA forms Product knowledge of PPO, HMO, IFP, FLEXNET, FIRST HEALTH, HOME HEALTH, CSP, HEMO/CHEMO, SPECIALTY PRODUCTS Analytical and payment accuracy review of client/member files, forms, pharmacy benefit claims PBM/PHM/SXC systemsEmployment History Benefit Integration Manager, American Health Care, Rocklin, CA Sr. Claims Development Specialist, Health Net, Inc., Rancho Cordova, CA Sr. Property Claims Adjuster, Prudential Insurance/USAA Insurance, Sacramento, CA Supervisor of Product Development, Classical Notes, Davis, CAEducation & Certifications Community Involvement & AchievementsBachelor of Arts Extensive volunteer history including involvementUniversity of CA, Davis (1996-2000) in community soup kitchens, working with theDouble Major: English and African & African-American Studies elderly, Golf fundraiser for the school for hearing impaired children, Annual Holiday Charity event forMasters of Business Administration foster children. Achievements include McNairUniversity of Phoenix, (2007-2008) Scholars, MURAL Scholars, Executive SecretaryConcentration in Business AdministrationManagement for the Greater Sacramento Urban League Young Professionals (2006-2007)CBEST Certification (2003)Relevant MBA Courses:MBA/510 MANAGERIAL DECISION MAKING MBA/570 SUSTAINABLE CUSTOMER RELATIONSHIPSMBA/560 ENTERPRISE RISK MBA/580 STRATEGIES FOR COMPETITIVE ADVANTAGEMBA/540 MAXIMIZING SHAREHOLDER WEALTH MBA/590 STRATEGIC IMPLEMENTATION AND ALIGNMENTMBA/550 RESOURCE OPTIMIZATION MBA/520 TRANSFORMATIONAL LEADERSHIP 2