Customer Service Support Specialist

Mark Wellesley

Professional Experience

Support Specialist

Monogram Health, Inc - Brentwood, TN May 2023 to Current

•Conducted outbound calls to existing patients, effectively gathering the necessary information and scheduling in-home care management visits and telehealth meetings.

•Coordinated patient home visit scheduling based on location and availability, ensuring efficient utilization of resources.

•Handled inbound calls with a positive attitude, building rapport and trust with patients.

•Utilized Salesforce to enter data accurately and maintain comprehensive patient records.

•Supported Monogram Health with various tasks to deliver personalized kidney care, demonstrating adaptability and a commitment to excellence.

•Fostered patient relationships and encouraged continued participation in healthcare services.

Pre-Authorization Coordinator

Huntsville Hospital – Huntsville, AL June 2022 to August 2022

•Proficiently utilized computer applications including Word, Excel, and EMR Billing systems such as Cerner.

•Demonstrated a strong understanding of medical terminology and medical billing processes, ensuring accuracy and compliance.

•Effectively managed insurance company requirements for services requiring referral, Precertification, or prior authorization, streamlining the approval process.

•Maintained effective work habits including regular attendance, dependability, and teamwork, contributing to a positive work environment.

•Supervised multiple facilities and clinics, ensuring adherence to protocol for submitting authorization requests and expediting urgent requests.

Receptionist

American's Best Eyeglasses and Contacts January 2022 to April 2022

•Represented the company with a positive and professional demeanor, providing exceptional customer service to patients.

•Managed daily patient schedules and demonstrated expertise in navigating vision insurance coverage, maximizing benefits for patients.

•Assisted opticians with dispensing frames, lenses, and contacts, ensuring accuracy and customer satisfaction.

•Supported store manager with inventory management and scheduling of contact lens classes, demonstrating versatility and a willingness to learn.

Lyft Driver (Part-time)

Lyft May 2017 to November 2021

•Provided transportation services as a part-time driver with Uber and Lyft, managing routes efficiently and ensuring passenger safety and satisfaction.

•Customer Service Representative II Medicare, Centene (A-1 Solutions) September 2019 to February 2020

•Responded to inquiries from members and providers within established timeframes, demonstrating proficiency in communication and problem-solving.

•Assisted members with website registration and navigation, enhancing their experience with the Medicare platform.

•Coordinated member transportation and facilitated requests and referrals, ensuring timely access to healthcare services.

•Maintained performance and quality standards based on established metrics, contributing to overall customer satisfaction and operational efficiency.

Customer Service Representative II (Contract)

Medicare, Centene September 2019 to February 2020

•Effectively responded to telephone and written inquiries from members and providers within established timeframes, utilizing up-to-date reference materials and available resources.

•Assisted members and providers with website registration and navigation, ensuring smooth access to online services.

•Coordinated member transportation and processed requests and referrals to appropriate departments, ensuring seamless service delivery.

•Maintained high performance and quality standards based on established call center metrics, including turnaround times, ensuring efficiency and customer satisfaction.

•Confirmed and clarified Pharmacy Prior Authorizations, Tiered Copays, and initiated Tier exceptions on behalf of members, resolving issues promptly and accurately.

•Conducted research to educate members on claims results and Explanation of Benefits inquiries, explaining the claims submission process to enhance member understanding.

Identified trends in incoming and outgoing calls to propose policy or process improvements, contributing to excellent customer service, quality improvement, and call reduction initiatives.

Case Manager Operations (Contract)

McKesson September 2018 to January 2019

•Engaged with healthcare providers and patients to manage appeals for claim denials, advocating for product-specific coverage per payer protocols.

•Monitored and managed drug coverage policies for multiple payers, identifying trends and key findings for reporting purposes.

•Conducted external research to identify alternate funding sources, expanding the internal resource database for future reference.

•Facilitated the prior authorization process for patients and healthcare providers, ensuring timely access to necessary medications and treatments.

Medical Claims Assistant (Contract)

Indian Health Services January 2018 to March 2018

•Audited, reviewed, and corrected errors in Emergency Room, Dental, Women’s Health, Pediatrics, Vision, and Pharmacy claims.

•Confirmed accuracy of medical records and resubmitted claims within Timely Filing guidelines.

•Handled contract position responsibilities with precision and attention to detail.

Emergency Room Registration

Banner University Hospital January 2017 to May 2017

•Managed patient registration based on the severity of their condition, ensuring efficient and effective workflow.

•Obtained patient insurance information, validated emergency room benefits, and collected copays or coinsurance premiums.

•Assisted uninsured patients in signing up for AHCCCS and submitted necessary information for enrollment.

Patient Financial Services Representative/Medical Billing

Banner Health Corporate July 2015 to January 2017

•Reviewed claims to ensure successful clean claim submission, maintaining high standards of accuracy.

•Investigated payment delays or denials by contacting payers and discussing claim details.

•Verified receipt of claims and facilitated resolution on unpaid or short-paid claims through effective communication with payers.

•Assisted patients regarding insurance inquiries, educating them on the claims processing process.

•Maintained meticulous documentation of work activities in the internal database for organizational continuity.

•Identified trends causing payment delays and worked to ensure timely reimbursement by payer contracts.

Reimbursement Specialist (Contract)

McKesson October 2014 to February 2015

•Utilized patient data to obtain vital health information within strict time frames, ensuring accuracy and timeliness.

•Followed up with insurance companies and patients to verify information and resolve discrepancies, while upholding confidentiality standards.

Provider Services Representative (Contract)

MODA Health May 2014 to October 2014

•Conducted comprehensive research and provided accurate benefit information to inbound callers, demonstrating exceptional knowledge of healthcare plans and policies.

•Reviewed and provided status updates on hospital and provider claims, Prior Authorization requests, and benefit information, while strictly adhering to HIPAA regulations and company guidelines.

•Confirmed and validated Prior Authorization status, and initiated the Prior Authorization process, ensuring timely approvals for necessary medical procedures.

•Analyzed claims to determine payment amounts, and effectively addressed discrepancies to ensure fair and accurate reimbursement.

Provider Claims Representative

AmeriGroup Healthcare October 2012 to April 2014

•Served as a Team Lead for a group of 10-15 Provider Representatives, providing guidance and support in resolving complex provider inquiries and claims issues.

•Assisted in generating reports and addressing questions and concerns from inbound providers, ensuring adherence to State Medicaid guidelines and company standards.

•Monitored team performance to ensure achievement of service level targets and implement strategies to improve efficiency and customer satisfaction.

•Facilitated training sessions and mentored new hires, offering valuable feedback and support to promote skill development and performance excellence.

•Acted as the primary point of contact for escalated situations, demonstrating strong problem-solving abilities and effective conflict-resolution skills.

Skills

•Excellent communication and interpersonal skills

•Proficiency in Salesforce, Microsoft Office Suite, and EMR Billing systems

•Strong understanding of medical terminology and billing processes

•Ability to multitask and prioritize in a fast-paced environment

•Attention to detail and accuracy in data entry and documentation

•Adaptability and willingness to learn new skills

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