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Customer Service Medical

Atlanta, Georgia, United States
May 21, 2018

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Todd E. Parham

P.O., Box ***, Atlanta, GA. ***** Mobile: 412-***-****


Experienced team player with a positive attitude having over fifteen years of working in fast-paced call centers demanding customer service and adherence to regulatory compliance seeking to leverage skill-set within the Medical Health Insurance field.



Risk Adjustment Used technology with ongoing analysis and expertise at optimizing risk adjustment and encounter reporting through several proprietary services. Enabled healthcare organizations to submit accurate and timely data, improve revenue and the quality of care in an efficient, proactive, and compliant manner. Auditing (HEIDIS) for Center Medicare/Medicaid Services. Provided efficient data submission to regulatory entities, continuous monitoring of risk scores, and identification of score gaps.

Member Services: Verified medical coverage eligibility with billing agencies, medical offices and Hospitals. Exceeded departmental daily quota of inbound calls (70). Advised if member participated in Home Maintenance Organization (HMO), Preferred Provider Organizations (PPO), or Point of Services

(POS) plans to third parties. Disseminated guidelines on COBRA for the unemployed and retired.

Multi-tasking, listening, inputting data, probing, providing solutions, navigating through various screens while applying basic customer satisfaction techniques

Coordinated and confirmed referrals of medical care for Out-of-Network and In-Network members relative to participating and non-participating care providers.

Quoted coinsurance, co-pays and applicable deductibles for In-Network and out-of- Networks members

Attending non-participating providers and practices.

Filed grievance and complaint reports. Advised Utilization guidelines for members who failed Pre-Certification and Pre-Authorization. Researched CPT and ICD-10 Codes for medical benefits and cost coverage.

Communicated drug coverage cost on formulary inquires for Brand and Generic prescriptions.

Located participating pharmacies for eligible members with commercial coverage.

Enrollment (Medicare/Medicaid/Commercial) Completed prospective members’ application during open and special enrollment of benefits and group Insurance programs: specializing in Medicare Advantage Plan D, Medical Saving Plans, and Private Fee for Service Plans and Stand-alone Medicare Part D in secondary markets. Managed several commercial reenrollment online applications.

Explained and interpreted retirement insurance programs to returning members and dependents during open enrollment season via interface communications.

Ability to work within a regulated environment and follow appropriate procedures and standards, i.e. Health Savings Accounts (HSA) and Health Reimbursement Accounts (HRA) and Flexible Spending Accounts (FSA); STD and LTD insurance premiums.

Sold AD&D, STD Buyouts and other Employer sponsored Supplemental Benefits.

Processed subsidies through Wellness Programs (Cooper) for reduce pre-tax premiums.

Addressed inquiries regarding coinsurances, co-pays, formulary tiers and participating

Pharmacies. Demonstrated conflict resolution skills resulting in member's satisfaction.

And hospitalization and medical coverage. Filled out online applications forms and verified information on forms submitted by members. Used NAVIGATOR, MedHok, PeopleSafe.

Coverage Determinations/Appeals Service Representative I, responsible for reviewing and processing Formulary Exceptions, Tier Pricing and Expedited requests from Primary Care Providers, LTC/SNF facilities, Specialists, Nurses and Members as mandated under Medicare (CMS) for Caremark (Pharmacy Benefit guidelines (HIPAA/PHI, Medicare/Medicaid).Confirmed eligibility through MARX.


Loan Counselor: Clarified various Loan Forgiveness, Postpone Payments, Deferment and Discharge Programs. Educated borrowers on Income Driven Repayment Plans: Revised Pay as You Earn, Income-Based repayment (IBR) and Income-Contingent Repayments (ICR) and various Consolidations methods and options. Reviewed files of delinquent and defaulted loans to determine repayment strategies aimed at keeping borrowers out of collections. Quoted Federal Reserve interest rates.

Determined status of customer's financial position prevents repayment of loan and justifies re-classifying loan as non-revenue producing. Quoted variable interest rates.

Multi-tasked through Word, Excel, Outlook, MicroSoft and websites.

Utilized National Student Clearinghouse, National Student Loan Data System; worked with Treasury Management (Dept. of Treasury). Issued Loan Verification Letters

Navigated borrower’s on company’s and Federal websites on troubleshooting.

Coordinated Rehabilitation on defaulted loans in conjunction with Third Parties.


Office Manager: Responsible for monitoring and reviewing systems, usually focusing on specific outcomes such as improved timescales, turnover, purchasing, budget management; both internal and external correspondence, accounting, record management, bookkeeping, facility management and customer service. Supervised two subordinates (contract employees) overseeing special assignments and projects.


Kelly Services, (Blue/Cross Blue Shield ( Anthem)) Pharmacy Information Agent 12/2017 - 01/2018

Buckhead, GA 30305 314-***-**** (Veronica Williamson, Recruiter)

Altegra Health Solutions (Hire Dynamics) Record Retrieval Specialist 01/2017- 10/2017

13010 Morris Rd, Alpharetta, GA. 678-***-****

Chimes Solutions (Hire Dynamics) 678-***-**** Customer Benefits Rep 10/2016- 12/2016

1000 Southlake Mall Circle, Suite 201, Morrow, GA 30260

Morneau-Shepell (New York Health Insurance (Sterling, Inc.)) Customer Service Rep 01/2015-10/2015 7 Parkway Drive, Green tree, PA. 15220 412-***-****

PHEAA (Pennsylvania Higher Education Association Agency) Loan Counselor 01/2014 –10/2014

11 Parkway Drive, Green tree, PA. 15220 717-***-****

Tufts Medical Insurance (BroadPath of AZ) Member Service Rep 09/2013-12/2013

Boston, MA. (Telecommuting) 520-***-****, Ext 418

CVS/Caremark (A-line-Services) Coverage Determination Rep 02/ 2013-04/2013

620 Epsilon Dr. Fox Chapel, PA. 15238 877-***-****

Aetna’s Medicare Part D (ACS/Xerox, Inc.) Enrollment Specialist 09/ 2012-01/2013

730 Holiday Dr. Ste 1, Green tree, PA 15242 1-800-***-****

Wilmer Engineering, Inc. Office Manager 06/2006-02/2012

Huntsville, AL 35802 256-***-****


University of Pittsburgh Business Administration (BS)

Pittsburgh, PA. 15260 412-***-****

United States Navy School of Journalism Certification of Completion

Pensacola, FL.

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