Terri Burton

Customer Service Advocate

Louisville, KY

ad2cnj@r.postjobfree.com

+1-502-***-****

Customer Service Rep. lll/ Medicare Coordinator/Benefits Specialist/Care Connector/Member Services Advocate/ Inbound Call Center

Authorized to work in the US for any employer

Work Experience

Medicare Coordinator/Customer Service Rep,lll.

Molina Healthcare Inc - Louisville, KY

August 2021 to Present

Resolves issues and addresses needs fairly and effectively while demonstrating Molina values in their actions • Provides product and service information, and identifies opportunities to improve our member and provider experiences • Knowledge/Skills/Abilities Responds to incoming calls from members and providers on a variety of issues of varying complexity, including highly complex issues • Completes research for state, legislative or regulatory inquiries as applicable • Gathers information to critically evaluate options, seeking alternative perspectives to identify root causes and develop solutions • Handles escalated calls on behalf of management • Provide excellent customer service • Accurately document all calls • Achieves individual performance goals as it relates to call center objectives • Engages and collaborates with other departments • Demonstrate personal responsibility and accountability by meeting attendance and schedule adherence expectations • Assists with training needs of employees as needed,

Business Analyst

TEKsystems - Louisville, KY

March 2023 to December 2023

Working from home/Reviewed and updated Medicaid Cases via Department for Community Based Services (DCBS) for clients who were Medicaid Eligible during Covid 19 and beyond. Outreached to conduct missing information on a client's application if needed and escalated the case to my Team lead or Project manager if needed. While ensuring that HIPAA GUIDELINES adhered to first and foremost. Benefit Specialist

Pharmacord, LLC - Louisville, KY

February 2020 to August 2021

Fast-paced Inbound call center, taking Inbound calls from consumers/patients/parents/guardians/and Health Care Providers for client's Dermira regarding drug Qbrexza, client myNeurelis regarding drug Valtoco, client Supernus regarding drugs Trokendi XR, And Oxtellar XR, and client Boehringer Ingelheim Cares Foundation conducting intake of consumer/ patients' demographics and Insurance Plan information in order to outreach to the patient's Pharmacy Benefits Manager(PBM) to verify if the medication is covered under their plan. I retrieve and explain deductibles, out-of-pocket, tier levels of medication, coinsurance, Prior Authorizations, and Medical Exceptions. If necessary I contact the Healthcare provider to provide Prior Authorization (PA) information such as phone or fax numbers that may be needed in order to submit the Prior Authorization. I also answer any questions within my scope to patients as well as Health-Care providers, I also download, read, and verify (while adhering to HIPAA guidelines) copay card and consent forms. I document all interactions. Transfer calls if warranted. I intake and send over any AE's(Adverse Events), PC's(product complaints), and SE's(Special Events) to our medical team as needed while on the call. I also Conduct outbound calls as needed to facilitate the patient assistance program

(PAP) for different medications, I outreach to providers to get prescriptions covered on a patient's behalf if none readily on file. I Follow through with and document all calls within the patient's case to ensure needs are being met. I triage and set up medication shipments as well as data enter documents into our system. I process Patient Assistance Applications. I transfer calls as needed. Report any and all Adverse Reactions (AE's) within timely filing procedures while adhering to HIPAA guidelines. Customer Service Representative 1

Anthem, Inc. - Anchorage, KY

August 2019 to February 2020

Answered a high volume of calls Utilizing dual monitors to obtain client information such as member ID or Social from state employees in regards to claims, health, dental, and vision benefits, and Explanation Of Benefits claims. Assisted Kentucky Employees Health Plan (KEHP) employees/members with deductibles, coinsurance, explanation of benefits (EOB's) calculated claims processes in network/ out of network, answered questions how much has been applied towards deductibles, out of pocket maximums, reset passwords, print/mail id cards via fax, or utilizing Anthem's systems software to have EOB's and ID cards sent via Right Now. Utilize dual monitors to obtain client information while strictly adhering to ALL HIPAA GUIDELINES, transferred calls as needed.

Care Connector Technician/Member Services Representative Evolent/Passport Health Plan - Louisville, KY

August 2016 to June 2019

Responsibilities:

As Care Connector/Case Manager I was responsible for supporting the organizations's goals of obtaining health needs, screenings, scheduling preventive service appointments and educating member's on plan benefits and services. Set up appointments/and or transportation for all Evolent/ Passport Health Plan members with their Primary Care Doctors (PCP), and or specialists via conference calls. Conducted outreach via telephone to members that showed as having Care gaps within their household's. Educated and explained the importance of preventative health screenings, while identifying any barriers to care. Educated providers about why the member couldn't keep appointments and why members need to be seen. Assisted members with Transportation resources as well as arranged for these services. All interaction about a member (s) was documented in the Identify System. Assisted with other Member services calls as directed in order to resolve premium/copay/eligibility issues and pharmacy issues; such as being in lock-in, medication denials, over-rides, and Prior authorizations for medications. Entered in Health Risk Assessment (HRA's) forms as required by the Department for Medicaid Services, received, date stamped HRA's, scanned HRA's into the system. Performed various other job duties as assigned via management/ and or Supervisor.

August 2016 -November 2017- Member Services Representative: Worked from office and Home

Provided first call resolution by active listening and having knowledge and confidence of what is being said and being relayed to the caller. Answered a high volume of inbound calls from State Medicaid members/prospects about enrollment, claims, and benefits. Utilized Care Mark Pharmacy Systems (CVS) for specific Drug Prior authorizations verified medications that a member may be on or prescribed, ran test claims to see why a medication may have been denied or approved, verified day's supply and quantity limits. Previously Utilized Citrix for handling the phone call /Aldera to find any Pre-Authorizations, claims, member provider changes, temporarily updated a member’s address to complete the process, or to order a Passport Health Plan ID Card (s) and Documentation. Daily Utilization of KY Health-Net Cabinet for Health and Family Services to verify status of current or past enrollment within the last 5yrs with Evolent/Passport Health Plan, Medicaid Medicare, Medicaid Waivers, and or any other Managed Care Organization (MCO) plan for verification purposes which included; Cost Share History met or not; Copay if any for medical and pharmacy benefits, Mailing addresses, and if caller is above or below the Federal Poverty Limit (FPL) I also sent other insurance information to be verified and updated via the Special Support Team via a third party entity.

Dispatcher/Customer Service Representative

Procarent/Yellow Cab /Inbound Call Center - Louisville, KY May 2016 to April 2018

Responsibilities:

Provided quality Customer Service by providing first call resolution, treating people with dignity and respect. Ensured smooth/efficient flow of vehicles/passengers to their destinations using MDT and telephones to determine types and vehicles necessary to complete different types of trips. Monitor vehicles/personnel locations efficiently coordinating service, schedules, and maintains reasonable driver workloads. Constantly monitored the overhead call situation screen utilizing DDS systems, read maps to see trip information to members and drivers. Took calls from drivers who were in accidents/incidents answered phone calls as needed if the call volume was deemed too high for the call takers, confirmed trip distances for drivers utilizing Google Maps, calculated time and distance using multiplication, adding, subtraction, and algebra to obtain the correct pay that is for these prepaid trips per phone call. Overseen breaks/lunches for the call center employees. Completed paperwork for breakdowns, accidents/incidents, and dispatched police if needed regarding the driver. Took credit card payments/information over the phone either from driver or passenger. Certified Nursing Assistant/Customer Service Representative Nazareth Home Outpatient and Rehabilitation - Louisville, KY October 2015 to June 2016

Responsibilities:

Answered residents' call lights promptly. Responded to all safety needs, turned residents every 2h or as deemed necessary. Bathed and groomed residents checked and changed monitored fluid intake/output. Documented all care given via kiosk while strictly adhering to ALL HIPAA GUIDELINES. I reported any concerns to my direct nursing supervisor.

Member Services Representative/ Inbound Call Center Gannett/Courier Journal - Louisville, KY

November 2015 to January 2016

Responsibilities:

Answered a high volume of incoming calls from members regarding billing, taking payments over the phone, assisting with password resets, notifying the correct department for escalation request and troubleshooting online problems for the customer. I place vacation holds/starts and provide credits for the clients.

Certified Resident Care Associate/Customer Service Trilogy/Glen Ridge Health Campus/Wesport Health Campus - Louisville, KY April 2012 to August 2015

Responsibilities:

Provided Customer Service to anyone, assisted residents with safety as well as their (Activities of Daily living) ADL's, such as feeding, bathing, grooming, and hygiene, while strictly adhering to ALL HIPAA GUIDELINES.Answered call lights in a timely fashion, took vital signs/weights. Documented all care given. reported any unusual findings to the Supervising nurse. Certified Nursing Assistant/Home Health Aide/Customer Service Family First Healthcare and Transportation Agency - Louisville, KY August 2013 to September 2014

Louisville, KY - August 2013 to September 2014

Responsibilities:

Assisted persons' in their homes with safety, grooming, medication reminders, toileting, dressing, feeding, provided companionship and some light housekeeping. Document all care given, while strictly adhering to ALL HIPAA GUIDELINES. I reported any changes to my immediate supervisor. Certified Nursing Assistant/Customer Service

Signature Healthcare East - Louisville, KY

January 2013 to April 2013

Responsibilities:

Assisted residents with their Activity of Daily Living (ADLs), answered call lights in a timely fashion, took daily vital signs, documented patient care via kiosk while strictly adhering to ALL HIPAA GUIDELINES, reported any unusual changes/finding to the nurse supervisor. Cleaned wheelchairs, turned resident's every 2h, as well as kept residents' dry, safe and comfortable. Certified Nursing Assistant/Customer Service

James Taylor Memorial Home - Louisville, KY

December 2008 to November 2010

Responsibilities:

Assisted residents with their activities of daily living, by bathing, feeding, clothing, taking VS, daily weights answered call lights in a timely fashion ensuring the safety of the resident while strictly adhering to ALL HIPAA GUIDELINES. I reported any unusual findings to the nurse, documented all care given under the delegation of a Registered Nurse.

Sitter/Certified Nurse Assistant/ Customer Service Maxim Healthcare Agency - Louisville, KY

September 2009 to February 2010

Responsibilities:

Sat with patients who were in critical condition, and who were at risk for harming themselves. I ensured patients' safety by sitting and observing, changes in a resident/client's behavior or vitals while strictly adhering to ALL HIPAA GUIDELINES, reported any unusual findings to the supervising nurse. Certified Nursing Assistant/Customer Service

Summerfield Health and Rehabilitation - Louisville, KY July 2008 to October 2008

Responsibilities:

Assisted persons with their Activities of Daily Living (ADL's), such as bathing, feeding, and dressing, taking vital Signs and daily weights taking while giving/showing respect for the resident, to help them maintain their dignity, and individuality, while strictly adhering to ALL HIPAA GUIDELINES. Answered call lights immediately and responded promptly to a resident's request. Reported and documented any unusual findings to the Supervising Nurse. Documented all care/procedures that were done. Member Service Representative

Humana Incorporation - Louisville, KY

May 2005 to October 2007

Responsibilities:

Answered a high volume of Incoming calls from prospective /members regarding their covered plan and or benefits, enrollment, plans, premiums, formularies, and eligibility in regarding Medicare part D, and or A & B coverage. Transferred all Medicare/Medicaid inquiries to the Center for Medicare and Medicaid as needed. I also took calls from pharmacies regarding prescription drug plans (Medicare/ Medicaid coverage). Promoted to the CMS processing unit to investigate, any Medicare eligibility claims resubmitted claims or eligibility enrollments via computer to the Center for Medicaid and Medicare services within a timely manner via the Claims Administration System (CAS). Reinstated member coverage by updating and/keying in members to a new plan, and or option, by process of analytical and critical thinking.

This included updating and correcting Social security numbers, Medicare identification numbers, and dates of birth/death. Researched a member's application/history to see if it was valid, by making sure a member had elections available to them. The application was then keyed in a detailed and timely fashion, making sure that it was on the correct transmit status codes. The application was then resent/sent to the Center for Medicare and Medicaid Services for updates/reviews utilizing the MARX System,while strictly adhering to ALL HIPAA GUIDELINES

Laborer/Customer Service Representative

Cintas Corporation - Louisville, KY

September 2004 to May 2005

Responsibilities:

Sorted garments for different companies such as Chemco, Ford, RC Cola, Etc Made sure that garments were in excellent condition via inspecting them in detail, for loose or frayed zippers wear and tear. Folded garments and hung them on a sorter line to be pressed, production quota was to be inspected 1500 garments Night. This required standing for periods of 8 or more hours per night. Member Services Representative

TKG Contact Center - Louisville, KY

July 1999 to August 2004

Responsibilities:

Answered incoming calls from different insurance companies such as Secure Horizons, PacifiCare regarding inquiries from Medicare and Medicaid members/prospects/providers about plan benefits billing, claims, eligibility, enrollment, data entered information in a timely fashion, updated billing information, processed over-the-phone payments. Updated members to a new plan option redirected calls to the proper department as needed. Followed and adhered to all HIPPA Guidelines. Education

Associate's Degree in Applied Sciences in Nursing

ITT Technical Institute - Louisville, KY

December 2010 to March 2018

Skills

• ALPHA-NUMERIC (10+ years)

• TELEPHONE (10+ years)

• CLAIMS (8 years)

• PHARMACY (8 years)

• Pega Systems (1 year)

• Microsoft SharePoint

• Managed Care (10+ years)

• Confluence (3 years)

• Insurance Verification (10+ years)

• Citrix (3 years)

• Sysco (4 years)

• Utilization Management (3 years)

• Agile

• Java

• Customer service (10+ years)

• Algebra

• Triage

• Communication skills

• Customer support

• Social listening

• Typing

• Windows

• SharePoint

• HIPAA

• Cold calling

Certifications and Licenses

CPR Certification

August 2023 to July 2026

BLS

Registered Nurse

July 2023 to January 2024

• This Provisional License is issued until I meet all of the licensure requirements for a permanent license.

• I am scheduled to take NCLEX RN Exam on 0/22/2024 Assessments

Customer service — Proficient

January 2020

Identifying and resolving common customer issues

Full results: Proficient

Indeed Assessments provides skills tests that are not indicative of a license or certification, or continued development in any professional field.

Additional Information

SKILLS

Trustworthy, Active Listener, Accountable, Empathetic/Sympathetic, Proficient in Microsoft Windows, some Excel, Claims Administration System (CAS), (Cisco Finesse Telephone), fax machines, kiosk, Care link, Matrix systems, and Caremark (CVS) pharmacy systems, Microsoft Outlook, Incentive Tracker, Aldera, Kentucky Health Net, Identify, Medhok, and Member call Tracker. Healthyfi, New Eyes for the Needy Application System, Language Line, Confluence Knowledge Base, Type 60wpm Alpha-Numeric, Clarity (Anthem's id Card system) DOS (Mainframe) Systems, Genesys, Well point Content Frame work (To look up 1500 Forms, UB40 forms(used to see diagnosis and procedure codes).ACAMP System

(to view a approvals, denials, letters, Diagnosis Codes, procedure codes in regards to Utilization Management).PEGA System (used to see a Member's First level appeal). CorScend

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