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Customer Service Quality

Location:
Thomasville, NC, 27360
Salary:
15.00
Posted:
March 20, 2018

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Resume:

Jennifer Spencer

ac4vdq@r.postjobfree.com 336-***-****

Trinity, NC

Skills:

Systems worked on :Facets, Carma Care Radius, UNET,Prime, PHS, Macess, Amisys

Excel, Microsoft Word, One Note, Access, Power Point

Processed claims with ICD 9 & 10 for medical and pharmacy

Processed Prior authorization's using current codes for ICD 10

Team Mentor for new hires for my department at Select Health

Learn new skills quickly and promote quickly,

Quality and production oriented have made my goals and made my quality each month once trained

Education:

Diploma in Certified Medical Administration, 2003-2004

Graduated with a 3.60 GP ECPI, Greensboro, NC

High School Diploma, 1995 Freeport Community College, Freeport IL

Work Experience:

SMA Claims Professional

Manpower, Winston Salem, NC 2017-Present

Process a variety of requests, inquiries and transactions via email, Macess, and Amisys

Process Medicare Advantage claims for Incoming Adjustments, Outpatient, Post Op, Ambulance, Timely Filing, SIU, Zero Fee queues in Amisys.

Support internal customers via email and Macess via service forms.

Meet Quality and Production goals daily and monthly.

Reviews requests via email for internal customers and service forms from various departments

Work with current ICD 10 procedural codes

Intake Specialist

Green Key Resource, Winston Salem, NC 2016-2017

Process a variety of requests, inquiries and transactions via phone, email, fax, and mail

Review requests to ensure accuracy

Support internal & external customers via phone or email

Document all pertinent information related to the call/inquiry, attach supporting information as applicable and if unable to resolve route to appropriate area for follow up as applicable

Gather and analyze data to provide feedback to Team Leads on employee development needs and/or specific providers requiring education on prior approval or pre-certification process

Screen inquiries to determine if authorization is required

Verify member benefits and eligibility and/or provider setup.

IN CARE MANAGEMENT OPERATIONS

Perform Peer Audits monthly as required

Provide clinical review outcome notification to members and providers (verbal and written)

Work on Carma and Care Radius to process prior authorizations.

Work with Current codes for CPT's and ICD 10, if needed convert ICD 9 to 10.

Pharmacy Benefits Specialist 2015 to 2016

Select Health, Murray, UT

Expeditious and accurate adjudication of pharmacy claims and the provision of excellent customer service to all members, employer groups, providers and other departments or teams

Rotated between pharmacy claims and customer service responsibilities in order to serve as a Subject Matter Expert in both of these areas

Processed and/or communicated multiple types of pharmacy benefits including coordination of benefits, direct member reimbursements, coinsurance benefits and mail order prescriptions

Provided superior customer service that is consistent with policies, company values and quality standards

Educated callers on correct use of their plans, including coverage of benefits, utilization, and administrative guidelines, in collaboration with teammates and other departments

Consistently demonstrated excellent customer service skills including problem solving, telephone etiquette, and responsiveness to customers

Ensured that all department phone standards and expectations are met pertaining to call statistics, production, documentation, and quality/accuracy

Efficiently and quickly addressed and solves problems on phone calls

Acted as a resource to all Pharmacy Benefit Specialist I employees for policy inquiries, questions, and problems that arise

Met or exceeded department standards for call time and answered call percentage in relation to the team average

Pharmacy Benefits Specialist

Select Health, Murray, UT 2013 to 2015

Processed and/or communicates multiple types of pharmacy benefits including coordination of benefits, direct member reimbursements, coinsurance benefits and mail order prescriptions

Handled incoming calls from members, providers, facilities, employer groups, and other departments.

Provided superior customer service that is consistent with policies, company values and quality standards

Educated callers on correct use of their plans, including coverage of benefits, utilization, and administrative guidelines, in collaboration with teammates and other departments

Made exception/empowerment decisions within the established exception policy

Consistently demonstrated excellent customer service skills including problem solving, telephone etiquette, and responsiveness to customers

Ensured that all department standards and expectations are met pertaining to call statistics, production, documentation, and quality/accuracy

Efficiently and quickly addressed and solves problems on phone calls

Exceeded department standards for call time and answered call percentage in relation to the team average

Issue Resolution Processor 2004 to 2013

United Healthcare Greensboro, NC

Resolved issues from members & providers & route to the correct department in an accurate & timely matter

Performed simple & complex adjustments for pre-existing claims & escalated issues

Tracked HCR Report updates to the Healthcare Reform Report each day

Corresponded with members and providers on status in claims

Claims Processor for UNET & Prime for all small and large group policies.

Processed all types of medical claims for inpatient, outpatient, office visits

Worked with current ICD 9 and CPT, HCPC codes.

Adjustment Processor: adjusted claims that were processed incorrectly thru the ORS database

Am Quality Certified: made 12 consecutive months with no errors & made Production Goals for 2012 /2013.



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