Darwin W. Fortner
I have 4 years of Case Manager and Utilization Management and Prior Authorization experience.
Has experience of supporting enterprise organization including, CIGNA, and BCBST
Extensive knowledge of ICD-9, HIPPA and FACETS, COBRA.
Customer Service/Call Centre Representative, Health Insurance, Service Desk, Managed Care Operator, Human Resources & Accounting professional.
Excellent Communication skills with the ability to interact effectively with all levels of an organization, & customers/clients.
Ability to make sound independent decisions, & problem solving.
Having great knowledge of Medical Terminology.
Proficient with Microsoft Office tools.
Customer Service (Call Center)
Ability to execute several programs simultaneously
Unified Functional Testing
Centers for Medicare & Medicaid Services (CMS) Security Clearance
Excellent Organizational Skills
10 Key & Data Entry
Microsoft Office 2010 proficiency
Cigna, Chattanooga, TN Oct 2018 – Feb 2019
Quality Review Audit Associate
I support the quality/audit team through the running of Unified Functional Testing (UFT's) and Validation Tool (PTVOBA)
Macro’s on multiple computer systems simultaneously. This includes allowing the program to create screen prints of documentation/tests to audit, as well as modifying drivers in Excel and watching for any errors that may occur while the program runs. I have a high level of communication with the auditors/testers while running their tests,
As well as the ability to multi task on multiple drives, using access database, Proclaim navigation, & e-Pro client contract.
Working knowledge of Microsoft tools required (Word, Excel, and Outlook); ability to manage multiple Virtual Desktop Interface, and manage priority accounts in a timely manner.
Wilkins Research Services – Chattanooga, TN
May 2018 – July’2018
Telephone Data Collection Interviewer
Collect data by conducting market research interviews by telephone and meet all standards of position requirements. Interviews are surveys and opinion polls regarding products and services used by consumers and business people.
Through use of a predictive dialer & Voxco Agent, interviewers will call individuals across North America to obtain opinions to complete questionnaires on various topics
Essential Functions and Responsibilities. Read verbatim scripted instructions and questions to respondents in a way that is clear and easy to understand. Solicit respondents to participate in surveys. Clarity and probe for answering (when appropriate), and answer questions from respondents using scripted responses.
Listen attentively and respond appropriately to respondents, but maintain a neutral and unbiased position.
Complete interviews with confidence and at an energetic, efficient and productive pace, while maintaining an acceptable Productivity rate.
Be creative, charismatic and confident, while maintaining a professional demeanour. Handle rejection, but do not personalize it.
Exercise extreme patience, professionalism, self-control, and no judgment when dealing with respondents.
Follow all policies including HIPPA outlined in the Wilkins Research Handbook. Must be able to give full attention to what other people are saying.
BlueCross BlueShield of Tennessee - Chattanooga, TN
Aug 2017 – Dec 2017
Medicare Advantage Enrollment Specialist
Robert Half - Office Team
Medicare Advantage Customer Enrollment
This position is also responsible for the maintenance (renewal configuration) on existing business including, but not limited to, benefit changes, rate changes, other miscellaneous changes and cancellations. Processing return mail
The enrollment specialist’s core function is to ensure BCBST remains competitive and markets a consistent, accurate and timely product in a professional manner. They are to ensure compliance to the internal and regulatory guidelines and develop a close partnership with marketing.
Evaluate medical, products and make decisions of insurability using established corporate underwriting eligibility guidelines, group master contract provisions and/or federal/state mandates such as HIPAA and COBRA, and using sound judgment to make decisions falling outside those guidelines.
Underwrite individual member applications (new and changes); successfully load membership data into FACETS and Sales Logix, when outside of workflow systems, and produce ID cards to assure members have easy access to care to the time of service and to facilitate timely and accurate claims adjudication for the member.
Manage daily inventory in a manner which produces timely and accurate decisions and accurate membership data.
BlueCross BlueShield of Tennessee - Chattanooga, TN
Jan 2017- Apr 2017
Customer Service Representative Provider Services Trainee
Responsible for handling calls coming from providers in regards prior authorizations and billing concerns.
Verifying insurance policies.
Responsible to managed cases using utilization management, to ensure that all tasks and procedures were appropriate, & necessary.
Working knowledge about FACETS, M360(Member 360)
Possess good knowledge about medical terminology. Handle Prior Authorizations.
Take appropriate action to resolve the question or complaint timely and accurately
Enter telephone inquiry report of contact into customer service intake screen
Maintain telephone performance goals established by the specified division
Maintain acceptable MTM quality accuracy based on division guidelines
Manage personal route list daily
Work with all departments in the division or company to resolve customer service inquiry issues
Ensure timely and accurate completion of daily/weekly telephone reports
State of Tennessee Dept. of Health- Nashville, TN
May 2013 – Jan 2017
Managed Care Operator/ Medicaid
Outreach/Outbound Educational Communication to clearly explain Tenncare policies by phone.
Outbound educational telephone calls regarding Dental, immunization, flu, & Zika virus, & Behavioural Health. Research data files & review policy & procedural information to answer questions & to identify & request changes that need to be made on the child’s TennCare coverage, Such as PCP change, using NPI Database to obtain information.
Finding accepting & specializing Physicians using, Find a Doctor, on BCBS, Amerigroup & United Health Care.
Manage cases using utilization management, to ensure that all tasks and procedures were appropriate, & necessary.
Verify Insurance. Handled Prior Authorizations. Scheduled medical & dental appointments
Analyze information, determine if processed & coded correctly, inform eligible enrollees of available services.
Handle complaints, settles disputes, & resolve grievances & conflicts, & negotiating with others. Dealing with ambiguity. Utilize spreadsheets & database to keep current on projects.
Work with the new Affordable Care Act policies.
Review records & verified information provided, for completeness, accuracy, & compliance with State and Federal guidelines.
Compile & documented information from various sources, Providers, MCO’s etc. & entered the data into the system.
Identify information by categorizing, estimating, recognizing inconsistencies/differences or similarities, & detect changes in circumstances or events.
Protected the security of medical records to ensure that confidentiality is maintained & HIPPA guidelines are followed.
Goodwill Industries of Middle Tennessee - Nashville, TN
Jan 2013 – May 2013 Call Centre Associate/Case Worker
Created profiles & determined eligibility by interviewing Goodwill career centre clients
Handle Administrative duties & responsibilities
Having effective & efficient problem solving skills, with world class customer service
Consistent high quality of service provided to internal as well as external customers
Fine-tuned understanding of soft phones and queue management
Clean Sweep Computer Repair Greenville, SC Nashville, TN
Dec 2001 – Jan 2013
Computer Repair Specialist
Build, assessed, diagnosed, issues, to repair & maintain computers & computer accessories, using specialized diagnostic tools.
Have experience with Microsoft 10, 8, 7, XP & Microsoft Suite, etc.
Provide on-call support for customers in a help desk environment.
Possess a strong technical ability to troubleshoot problems to resolution.
Installation & Education of software.
Install & configured local area data communications networks.
Resolve network communications problems to ensure user’s access.
Teletech for U.P.S. - Greenville, SC
May 2001 – Nov 2001
Customer Service Representative
Provide high industry standard customer service.
Verify Information, data entry.
Scheduling pickups, & gave estimates.
Prettl Group - Greenville, SC
Mar 1999 – Apr 2001
Inventory Account Clerk
Manage inventory, I did the auditing, bookkeeping,
Accounts receivable, accounts payable, 10 Key & data entry
Coordinate & facilitated the acquisition of goods and services.
Responsible for Administrative duties
Verify inventory, managed warehouse inventory
Procurement/supply chain Negotiated for better prices
Research online for better quality parts & prices
Nannies for Grannies - Greenville, SC Jan 1991 – Feb 1999
Manager/Co-Owner- In Home Convalescent Care
Managed 15-20 employees, & scheduled the CNA staff. & Patient Care
Contractual Agreements, Reconciliation of delinquent accounts
Interviewed, did the Background, References checks.
filled in for absent CNA’s
Credentialing CNA’s for recruiting using South Carolina Nurse Aide Registry Search.
In charge of Training & Development for the CNA’s
Helped Patients stay current with their medications, & Physicians recommendations, & Health Insurance, Medicare & Dr's Appointments.
Handle Conflicts, handled complaints, settled disputes, and resolved grievances and conflicts, or otherwise negotiating with others.
Take care of all the Administrative duties & responsibilities.
In charge of Business tax filing/ Individual income tax preparation
Hot Spot Convenience Store - Greenville, SC Nov 1989 - Jan 1991
Manage daily store operations including store financial performance.
Interviewing, Background, Employment & Reference verification for recruiting & acquiring strong performers.
Scheduling cashier staff.
Cash control, fuel, inventory, customer service.
Inventory stock & re-ordered.
Complete all relevant paper work to include daily & weekending reports.
Maintain cash inventory, banking & cash transactions
State of Tennessee- Nashville, TN April, 2015
Fundamentals of Facilitation Workshop
Greenville Technical College- Greenville, SC July 1987
Business management course
Lee College- Cleveland, TN May 1983
Math, Biology, Physic Ed
Greenville Technical College- Greenville, SC May1982
Math, Biology, Physic Ed
Greenville Technical College- Greenville, SC May 2001 - Aug 2001
A+ Certification computer courses