Customer Service Representative
Resume:
Deborah Manago
Boston, MA *****
**************@*****.***
OBJECTIVE:
Seeking a position in Customer Service where my extensive experience will be further developed and utilized.
Employment:
Tufts Network Health Plan
Medford, MA
August 2014 – Present
Claims Processor
Process core claims adjustments as assigned by supervisor:
Review adjustment request to determine if re-adjudication of claim is required.
Examine claim to correct and/or update data so claim can properly re-adjudicate.
Prepare and enter adjustment while applying appropriate back out and adjustment reason codes.
While processing claim adjustment, ensure that claims maintains or is appropriately updated to:
Correctly reflect Tufts Health Plan's status as primary or secondary payer through the appropriate coordination of benefits.
Member was eligible on DOS.
Services rendered on the claim are allowable under the members benefit plan and/or the proper authorization, referrals and pre-registrations were obtained as required by the plan.
Reflect correct pricing, which may need to be applied or manually re-calculated.
Communicate with partner departments (verbally and/or written) to obtain missing information to properly re-adjudicate claims, such as provider numbers, authorizations and referrals.
Boston Health Net Plan
Boston, MA
February 2012 – July 2014
Member Service Representative
Responsibilities:
Served as the primary liaison for Mass Health and Commonwealth Care members regarding general program inquiries such as eligibility verifications, authorizations, referrals, material fulfillment, address changes, and Primary Care Physician assignments and member related policies and procedures.
Identified customer issues/concerns rapidly and precisely
Assisted members with re-determination inquiries
Research required information using available resources
Handled and resolve customer complaints
Identified and escalate priority issues
Route calls to appropriate departments
Initiated follow up customer calls
Completed call logs to record customer interactions and transactions, recording details of inquiries, complaints, and comments, as well as actions taken
Referred customer grievances and appeals to designated departments for further investigation.
Navigating multiple systems in order to resolve member issues
Performed outreach Calls or surveys as required for new members
Network Health Plan
Medford Ma
December 2011 - January 2012
Claims Processor
Responsibilities:
Responsible for claims review, clearing claim edits, and timely and accurate submission of claims
(both electronic and paper). Received incoming calls from providers regarding status of claims.
Tufts Health Plan
Watertown, Ma 02472
September 2011 – December 2011
Sales/Triage Representative
Responsibilities:
Sales/Triage: Provide detail information of products and services offered and available to Medicare Preferred members.
Maximus
55 Summer St Boston MA
September 1996 – February 13, 2011
Health Benefit Advisor
Responsibilities:
Served as a Health Benefit Advisor for all mass-health members, providers regarding benefits, claims resolution, pharmacy issues, eligibility, material fulfillment, premium rates, provider contracting, policies and procedures.
Responsible for navigating multiple systems in order to resolve member and provider issues.
Assisted and educated members about their health plan choices.
Enrolled members into various a health plan of their choice.
Processed member’s premium payments and help members resolved issues regarding premium billing issues.
Assisted members with issues regarding eligibility.
Mailed out Mass-health application or Eligibility Review form to members.
Assist members with transportation issues.
Assist providers with billing or claim issues
Reprocess non-complex incorrectly processed claims at the time of calls and coordinating complex claims resolution with Claims Services.
Accurately log all member and provider inquiries into eligibility database
References: Available Upon Request
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