Customer Service Data Entry

Dana Leigh Hills

****.******@*****.***

203-***-**** Mobile

Extensive knowledge of the medical insurance world from management, customer service, claims, network, credentialing, PBM, membership, enrollment & billing, contracting, fee schedule negotiation, mentoring/training, Medicare/Medicaid, as well as knowledge in HIPAA, PHI, URAC & NCQA requirements.

To obtain a career with growth opportunities that will allow me to use my knowledge & creative nature to help myself and to mentor others to become successful. PROVIDER ENROLLMENT ANALYST- PALMETTO GBA

3/27/2023-Present

To enroll groups & providers into the Medicare network. Requesting missing information as needed following the guidelines for deeming an application complete or incomplete. Following up via phone or email with providers, groups or contacts in a timely manner regarding any questions with submitting their applications. Issuing PTAN’s/PINS as needed. Completing data entry into PECOS. Navigating IFLOW, PECOS & MCS. Processing SARW, Revalidations, Reactivations and Change of Information Requests, while maintaining excellent productivity and quality metrics. PIV issued. REALTOR-GREAT ESTATES CT LLC

August 2013-Present

2019/2024 Five Star Professional Award Winner

2018 Quality Service Producer Award Winner

Buyer Side of the transaction: To find them the best property, at the best price, navigate the transaction through escrow, while protecting the clients' interest. Seller Side of the transaction: Duties are similar; however, I also have to price & market the clients' property & assist in finding a qualified buyer.

Writing contracts and negotiations are done for both the seller & buyer. DEA VERIFICATION SPECIALIST- ACE SOUTHERN (TEMP POSITION) 2/1-3/24/23

Upload new DEA forms to expedite controlled substance orders DINING EXPERIENCE CONNISUER- LIL DUCK TREEHOUSE & KOMBUCHA October 22-Feb 23

Waitress and special event coordinator

ASSOCIATE NETWORK CONTRACTOR-EWINGS INC

(Temp assignment) 2021-2022

NE, NJ & PA- Recruiting eligible providers, to the Partners Direct Health Self Insured Plan, negotiate fee schedules, submit contracts, answer any pertinent questions or refer to Sr. Contractors if we cannot come to a fee schedule agreement.

PHARMACY TECHNICIAN-CVS

Appeals & Grievances Consultant

Accts Receivable Analyst

Oct 2021-Oct 2022.

CPhT. 2019-2023

Data Enter New prescriptions, verify insurance, fill medications, Inventory Mgmt, assist pharmacists with other various duties.

PROVIDER CONTRACTING ADVISOR- CIGNA (TEMP ASSIGNMENT) September 2019- May 2020

I worked with Medicare Part D Network Operations, our Pharmacy Benefit Manager (PBM) and the Retail Channel Management (Formerly Pharmacy Network Operations) on a variety of pharmacy network related projects.

The position leveraged Medicare subject matter expertise in support of the successful operation of Network Operations partnering.

with the PBM and vendors in multiple areas, including network composition, beneficiary complaints/grievances, and CMS Medicare

requirements, including knowledge of Medicare guidance and requirements, and Medicare Part D products and services.

I assist with readiness and accuracy in Network Set Up, adequacy and reporting, As well as handle network inquiries, audit protocols,

network communications and monitoring to ensure CMS and Internal requirements are met and supported.

Here are some of my additional Responsibilities:

Assist with various Medicare related items including Medicare Plan Finder, Network Composition / Geo-Access reporting and Star Ratings. Assist with support of CMS requirements, and delegated activities. Assist with all CMS requests and/or audits, including assisting with oversight of the subrogation compliance vendor.

Assist with responses to pharmacy network related complaints and/or grievances. Work towards continuous process improvements within the department Assist team in creating and maintaining process flows. Responsible for assisting with development, implementation, and distribution of communications regarding policies, practices and procedures.

Monthly monitoring of member pharmacy claims/EOB's ensuring that the members pharmacy claims are processing correctly, that they are in the correct benefit phase, and the appropriate deductible, co-insurance, extra help/LIS/other insurance carrier information is processing correctly based on formulary & Medicare Advantage benefits.

MEMBERSHIP ENROLLMENT SPECIALIST-ANTHEM BCBSCT

August 2019-September 2019

Responded to incoming calls and may initiate outgoing calls, providing customer service to plan members, providers, and employer groups by answering benefit questions, resolving issues and educating callers. Verifies enrollment status, makes changes to records, research, and resolves enrollment system rejections; addresses a variety of enrollment questions and/or concerns received by phone or mail.

Ensures accuracy and timeliness of the membership and billing function, including processing group payments and issuing email confirmations. Responds to inquiries concerning enrollment processes. Maintains enrollment database, Including ordering identification cards. Determines eligibility and applies contract language for each case assigned. Performs error output resolution for electronic eligibility and processes error discrepancy list. Screens all forms and data for all paperwork received from Sales and/or underwriting for new group and/or group re-classing benefits. Makes request to Underwriting, Sales or Brokers for missing information and/or forms needed for new group or re-class of existing group. Screens group for benefits to determine if existing or new, recognizing when benefits are not standard and handling as appropriate. Thoroughly documents inquiry outcomes for accurate tracking and analysis. Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner. Performs basic job functions with help from co-workers, specialists and managers on non-basic issues.

SR. CREDENTIALING ANALYST- AETNA

July 2005- Jan 2019

I assist providers through the navigation and the completion of the credentialing process. Helping them to follow the correct procedures to become an Aetna provider. Contact with the provider or credentialing contact to ensure their CAQH online application is accessible, ensuring all the necessary documents are present, i.e.: DEA, CDS, Malpractice Insurance, license, practice locations, they have completed the confidential questionnaire and signed an attestation, that is no more than 180 days old.

Training and mentoring new analysts as well as putting together training material, sending out updated communications or handling a refresh on some of the current procedures, not only to improve efficiency, but quality as well. Collaborate with my team, and department always looking for best practices, and ways to save our department and Aetna any unnecessary costs Working with SIU on any providers that may have sanctions, fraud, DUI's, malpractice, or code of conduct accusations, to ensure the safety of our members. Researching the history behind the information received by either the application, NPDB or state licensing board. Manager Back Up, including but not limited to delegating the daily workload based on priority and state required TATs, auditing, putting the file back into verification, ensure shipping is done on our required time schedule, and that all the elements that have been verified, will expire after they have been reviewed at the committee meetings, timecard approvals, weekly production reports, daily inventory reports. Conduct weekly meetings via virtual sessions, research any providers that have been recently approved, but not yet linked in the payer system, always ensuring that the provider is satisfied of any questions that may arise, regarding network approval. Assisting in any issues that may arise to the providers' satisfaction. Have provider ID's / Pins unlocked, team point person for any upgrades, send state required letters if there is any delay in the credentialing process. I was on the team working on the Tricare acquisition, helping with contracting and rate sheets for the potential providers. I was an EAC member & one of the editors of our departments Healthy Lifestyles and Wellness Newsletter. CUSTOMER SERVICE/BLUECARD CLAIMS SPECIALIST- ANTHEM BCBSCT MAY 2001-JUNE 2005

Customer Service Representative PSCBU

Member services representative. I take incoming calls, answer members questions on claims and benefits, mail inquiries, helping other reps with benefits issues and questions, as well as taking supervisor requested/escalated calls, at the same time maintaining an among the best both in productivity and quality.

Bluecard Claims Specialist

Process and adjust claims, Medicare, commercial, hospital, COB Investigate why claim rejected originally and work directly with customer service in resolving the claim issues. Prior to taking this role, Bluecard claim processing took up to 90 days & in some instances longer, I was able to reduce that to an under 30 days TAT in most cases. OWNER/OPERATOR OF HILLS CONSTRUCTION, LLC

4/2009-5/2022

Run daily activities for residential construction & remodeling company. Provide Estimates, Pull Permits, Order Material

Finalize job site, date, times etc.

Accounting, Customer Service, Financing Options

Make sure Sub-Contractors were appropriately placed at job sites. Finalize timelines, work with town, building depts and other Sub-Contractors to ensure a seamless job site from start to finish.

Prepare and Mail out 1099 forms at tax time

STORE DIRECTOR- HOLLYWOOD VIDEO

June 1997-May 2001

Daily store activities; hire and train staff, customer service, cash handling, supply orders, and keeping a store revenue & presentation

to be proud of.

REFERENCES AVAILABLE UPON REQUEST

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