Customer Service Utilization Management

Nicole Jack

Phone: 813-***-**** Email: *********@*****.***

PROFESSIONAL SUMMARY

A highly driven analytical and goal-oriented healthcare professional with 6+ years of experience in prior authorization and utilization management. Proven expertise in delivering excellent customer service, maintaining high standards of communication, and fostering strong relationships with internal and external partners. Adept at problem-solving, project management, and leading teams to meet business operational objectives.

SKILLS & COMPETENCIES

- Claims Operations

- Database Management

- Clinical Data Analysis

- Root Cause Analysis

- Process Improvement

- Team Leadership & Training

- Salesforce CRM

- SQL Programming

- Microsoft Office Suite

WORK EXPERIENCE

*BCBSFL 08/2020 – Present

Utilization Management II

- Provided world-class customer service to plan members and providers, resolving issues and answering benefit questions with a focus on detailed understanding of products and services.

- Acted as a liaison between hospitals, physicians, health plans, vendors, patients, and referral sources, managing clinical referrals for members.

- Verified insurance coverage and obtained authorizations, adhering to internal policies to avoid data discrepancies.

- Played a key role in team success by training with the supervisor and mentoring junior members, ensuring alignment with company goals and customer service standards.

- Demonstrated strong written and oral communication skills through educating members and facilitating onboarding training for new staff.

CVS Health Remote 02/2018 – 11/2019

Lead Benefit Data Analysis

- Showcased excellent analytical skills in exploring data to determine trends and guide business strategy, ensuring timely resolution of discrepancies.

- Cultivated relationships with key client partners through a consultative approach, understanding client benefit plan design needs, presenting solutions, and overseeing implementation for service satisfaction.

- Consistently met turnaround time and performance guarantees, earning praise from leadership.

- Facilitated internal and external meetings, providing status updates and decision-making on client’s benefits setup.

- Conducted periodic audits of business systems to ensure data quality and accuracy.

Cognizant Tampa, FL 07/2016 – 08/2017

*Sr Process Executive/Utilization Management

- Responded to inquiries from healthcare professionals about Medicare, Medicaid, and Commercial policies, delivering exceptional claims support.

- Served as a liaison between Grievance & Appeals and other departments, resolving claims inquiries.

- Facilitated training for new hires and provided expertise on proper procedures to resolve client concerns.

- Supported process and quality compliance certifications and process improvements.

- Demonstrated leadership and problem-solving skills in managing escalated customer complaints and issues.

Wellcare Tampa, FL 04/2014 – 07/2016

Prior Authorization Representative/Utilization Management

- Delivered exceptional customer service by resolving benefit questions and issues.

- Acted as a liaison for clinical referrals, ensuring thorough understanding of company products and services.

- Verified insurance coverage and obtained necessary authorizations, adhering to detailed procedures to avoid data discrepancies.

EDUCATION

Full Sail University 2023-present

Information Technology

Concorde Career Institute

Pharmacy Technician Diploma

Richard Arnold

GED

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