Customer Service Call Center

Tina Swain

Cleves, OH *****

Contact – 513-***-**** ***********@*****.***

PROFESSIONAL PROFILE

Customer service oriented professional with vast hands-on healthcare industry experience, capable of

ensuring smooth patient flow by providing prompt attention to pulling patient charts and necessary

medical records. Gathers accurate billing and financial information and reviews intake materials for

accuracy and completeness. Reviews ICD-10 codes and CPT codes for accuracy before submitting

medical claims for reimbursement. Extensive knowledge of Claims Life-Cycle and Revenue Cycle

Management. Simplifies health insurance so that the patient is educated on how their claims are paid

for services rendered by a healthcare provider or healthcare facility, by providing detailed explanation

of their EOB. High level of knowledge with CMS guidelines with DSNP’s, or Dual Eligible, LIS,

Medicaid’s Low- Income Subsidy’s, and MCO’s, or Managed Care Organization. Vast knowledge of

CMS Guidelines for Medicare and Medicaid in various states including, OH, KY, FL, IN, DE, WI, MI, GA,

NJ, TX, MO, IL, and TN

Accustomed to a fast-paced call center environment, handling up to 100 plus calls a day in an 8

hour shift

Strong understanding of the importance of accurate claims processing

Attention to detail needed to review and correct errors and maintain high levels of accuracy

Microsoft Office Applications / MS Excel MS Word MS PowerPoint MS Outlook Microsoft

365 Teams

Computer Software: Member 360 CSA Streamline E-scripts Allscripts Bonafied Brightree

Omni Finesse True Care & TrueCare Cloud Genesys and Genesys Cloud Facets Multiple

Billing and Coding software and platforms

Typing Speed: 65 WPM

KEY QUALIFICATIONS

Medical Practice Management Systems Medical Terminology Medical Records HIPAA

Compliance

Insurance Verification Insurance Claim Processing Reimbursement Processing Revenue Cycle

Management

Medicare Medicaid Government Payers Third Party Payers CPT & ICD-10 Coding

Medical Billing Medical Office Medical Administrative Patient Registration Data Entry

Pharmacy Prior Authorization Benefits & Eligibility Explanation of Benefits

Coordination of Benefits Utilization Management Time Management Commercial Payers

EDUCATION

Ultimate Medical Academy Associate of Science Degree Health Sciences – Medical Office and

Billing Specialist, 2022

Ultimate Medical Academy HIPAA Essentials for Healthcare Professionals Certificate

Certified Billing and Coding Specialist Enrolled in Google Data Analytics Certification through

Coursera Academic Recognition – Honor Roll January 2021- Dean’s List Award March 2021

PROFESSIONAL EXPERIENCE

Bswift

10/09/2023-11/20/2023

Service Center Agent

Tina Swain Cont.

Utilized multiple systems and screens to verify member information and research issues to provide

solutions

Provided excellent customer service in an inbound, fast paced, high volume call center to enroll

members during Open Season

Centene Corporation- Meridian Medicaid MI Farmington, MO 04/2023

– 08/2023

Member Services Representative

Utilized multiple systems and screens to verify patient information and research issues to provide

solutions

Provided excellent customer service in an inbound call center for Meridian Medicaid Michigan Members

Resolved issues and answered questions regarding DSNP, LIS, and MCO members

Verified Benefits & Eligibility

Verified ICD-10, HCPCS, and CPT codes were accurate and billable per plan policy

Exceeded quality expectations and performance goals set by Workforce Management

Cigna Health Group–Kansas City, MO 08/2022 –

04/2023

Utilization Management

Utilized multiple systems and screens to verify patient information and patient charts.

Organize and collect data for the billing sheet and submit data entry daily.

Make the patients information match up to the corresponding encounter sheet.

Assisted physicians’ offices, healthcare facilities, hospitals, and pharmacies with obtaining prior

authorization for upcoming procedures and services, inpatient hospital stays, and outpatient services.

Verified Benefits & Eligibility

Verified ICD-10, HCPCS, and CPT codes were valid and billable per plan policy

Verified if members were part of DSNP, LIS, or MCO plans for various states including Michigan,

Delaware, Ohio, Kentucky, Indiana, and Florida

Advanced knowledge of Medicare and Medicaid guidelines for various states that includes, Michigan,

Delaware, Ohio, Kentucky, Indiana, and Florida

Anthem Federal – Cincinnati, OH 07/2021 –

04/2022

Claims Customer Service Representative

Enter medical codes, answer inbound phone calls, and help members enroll into patient portals

Advise callers of benefits and eligibility for medical services to be performed, as well as advising of

copays, coinsurance, deductibles, out of pocket maximums, total costs, and whether services require

precertification

Advise members on the status of their healthcare provider and mail out plan brochures and member

identification cards

Demonstrate professionalism, critical thinking, effective communication, cultural competence, and

interpersonal skills

IngenioRx– Mason, OH 11/2020 –

03/2021

Customer Service Representative

Provided exceptional customer service to members, healthcare providers, hospital staff, pharmacists,

and skilled nursing facilities with obtaining prior authorization for prescription medications

Went above and beyond what was expected in order to assist more than 100 callers per day that

needed to fill prescriptions

Utilized critical thinking skills, actively listened to callers, and entered medical codes

Verified if members were part of DSNP, LIS, or MCO

Tina Swain Cont.

Verified and updated Coordination of benefits, or OHI

Mullaney's Pharmacy and Home Health – Cincinnati, OH 02/2020 –

07/2020

Customer Service Representative

Trained new hires, entered medical codes, and assisted customers entering the store

Provided support to all 5 Mullaney's stores by traveling to their location to provide coverage when the

store was short staffed

Processed prescriptions for medical equipment and supplies and answered inbound phone calls

Operated multiple software programs, obtained supporting documentation, and prepared orders

Verified if patients had OHI, COB, DSNP, LIS, or were part of an MCO

Adhered to CMS guidelines

Medisync – Cincinnati, OH 05/2018 – 11/2019

Patient Account Representative

Reprocessed claims, entered medical codes, and trained new hires

Provided exceptional customer service to more than 100 callers per day in a medical billing call center

Demonstrated critical thinking, effective communication, organizational, and interpersonal skills when

assisting patients who had questions concerning their explanation of benefits for recent office visits with

their healthcare provider

Set up payment plans for patients with high balances and who were in collections for past due balances

Led team building exercises in order to obtain payments on aged collection accounts

Trained new patient accounts representatives on the software the department used to look up patient

accounts, software used to process payments over the phone, and call coaching when taking calls from

patient's calling into the call center

Acted as liaison between the health care provider and patients if there was a complaint with the medical

office

Processed self-pay refunds on patient's accounts if there was a credit balance due to the patient

Verified and updated COB, OHI, DSNP, LIS, or were part of a MCO

Bernens – Cincinnati, OH 07/2016 –

04/2018

Customer Service Representative

Answered inbound phone calls, maintained inventory levels, and ordered supplies

Entered medical codes, verified insurance, accepted payments, and called in referrals

Trained new hires, upsold items, enrolled new members, and completed end of day paperwork

Verified Benefits & Eligibility and obtained prior authorization for medical equipment and supplies

through health plan if necessary

Verified ICD-10, HCPCS, and CPT codes were valid and billable

Verified if patients were part of DSNP, LIS, or MCO

We Care Medical – Somerset, KY 04/2013 – 06/2016

Site Coordinator

Ordered inventory, trained new employees, and entered medical codes

Dispatched delivery drivers, handled new patient intake, and verified Benefits & Eligibility

Acquired prior authorizations, updated demographic information, and utilized Brighttree to schedule

appointments

Verified OHI, verified and updated COB

Verified if patients were part of DSNP, LIS, or MCO’s

Tina Swain Cont.

LinkedIn profile http//:www.linkedin.com/in/tina-swain-b3405a211

References available upon request

Contact this candidate