Customer Service Associate

Sabrina Deloach

Phone: 813-***-****

Email: **************@*****.***

Highly personable professional seeking a career opportunity in a distinguished healthcare organization allowing me to utilize my vast skills and knowledge to better an organization including:

Organized, dependable, able to learn new tasks quickly, highly motivated, team player and excellent communicator.

Seeking a position where I can utilize my organizational, communication, and listening skills Expertise in resolving escalated customers’ service issues.

EDUCATION & RELATED EXPERIENCES

Jefferson High School-Senior level 08/1981-05/1985 Various Customer Service Seminars

Customer Interface, (CI) ICD 9 codes, CMS 1500 UB-904 and PBS Billing System Training

Proficient in Microsoft Office suite

HC Medical Terminology

Statistics

Present Cognizant Tampa, FL

Pharmacy Customer Service Associate

Pricing

J Codes

Billing Insurance

Knowledge of Medication and Pharmaceutical Products

Identify issues and communicate solutions and steps to customers, pharmacies and physicians Present Cognizant Tampa, FL

Senior Executive Claims Analyst

Adjudicate claims in accordance with policy terms and conditions.

Achieve / exceed set productivity and quality standards.

Interface effectively with internal staff to resolve customer issues.

Reviews and processes claims of varying complexity levels.

Using complex systems to research, analyze, and price claims in accordance with processing guidelines as well as provider and customer contracts.

Identify potential process improvements and make recommendations to Team Leader Present Cognizant Tampa, FL

Appeal & Grievances Specialist

Identifies, coordinate and route medical and pharmacy appeal accurately and timely. Initiate case files for each file appeal and ensure compliance with organizational and regulatory requirement.

Respond to complains grievance and appeal in consistent fashion, adhering to all regulatory, accreditation and internal processing timeliness and guideline.

Responsible for the timely and accurate document of the grievance or appeal both electron and in hard copy.

Respond to written and /or verbal grievance complaint sand appeal submitted by provider in accordance with the regulation of the CMS, DOH and other entitle, conducts through investigation of all relate provider correspondence through fact finding review to understand all the issue involved.

Obtain response and require information form intern and external entities accordingly, Interface with various department delegated entities, medical group a network physician to ensure timely resolution of case and determine proper responded based on type of grievance or appeal submitted using independent judgment.

Prepares all initial and final adverse determination letters. February 2015- June 2017 Financial Credit Solution/ Gulf coast Collection Bureau Tampa, FL Claim processing/Billing

Process A/R

Verify Eligibility

Collection

Update accounts

Process Payments

Process consumer request

Verify Medicaid/Medicare

Experience

May 2013 – October 2014 Intraligh Intra-Operative Support Tampa, FL AR Patient Collections Specialist

Responsible for identifying contractual, and A/R trends

Processed Appeals

Post Payments/Collection

Provided exceptional customer service to Medicare, Medicaid, PFFS and Part D policies

Maintains knowledge of third party contracts and communicates with affected staff members any issues and/or change in policies to ensure clean claim submissions.

Knowledge of government and insurance regulations

Maintain monthly Bankruptcy reporting

Handled escalated member complaints/

October 2012- April 2013 United Health Corporation Oldsmar, FL Retiree Reimbursement Accounts

Review claims for reimbursement

Review contribution for posting for each of the groups

Updated base when necessary

UHCBS Billing/Senior Customer Service

. Inbound calls for United Health Care Benefits Services, Administration for Cobra Billing

Posting payments/Collection

Posting & taking payments from our clients

Review all contributions from all employee groups were posted

Review eligibility

January 2011- April 2012 Freedom Health Tampa, FL

Team Auditor/Claims

Processed hospital/medical claims

Performed adjustments

Reviewed claims inquiries

Processed Appeals

Handled escalated member complaints/provider issues/COB issues

Worked on special manager projects

January 2008- January 2011 Well care Tampa, FL

Senior Claims Rep

Resolved escalated claim issues

Reprocessed for providers and educate them on information needed to receive payment

Tracked/followed up on all provider related escalated inquires for refund, checks issue and non-receipt payments

Answered incoming provider escalated calls for Medicaid, Medicare, PFFS and Part D insurance lines of business

Served as back up for the over flow of member calls

Acted as liaison between the provider representative and for making updates on provider files January 2005-December 2007 Genitive Tampa, FL

Billing/Enrollment-Rep

Reviewed claims inquiries/ performed minor adjustments

Provided exceptional customer service to Medicare, Medicaid, PFFS and Part D policies

Handled escalated member complaints

Processed billing/premium payments inquiries and reimbursements

Resolved enrollment issues for members

Reference Available Upon Request

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