Customer Service Resolution Specialist
Resume:
La Tonia Lofton-Adams
Houston, TX *****
*************@*****.***
To obtain a position that will enable me to maximize my diverse skills and education in a manner that will provide growth and opportunity as an asset in your organization. Authorized to work in the US for any employer
Work Experience
Appeals and Grievance Resolution Specialist
TTEC Healthcare Solutions(UnitedHealth Group) - Houston, TX August 2021 to Present
• Initiate appeals and grievances for Medicaid/ Medicare recipients
• Analyze all denied medical, dental, vision claims and predeterminations to best confirm criteria based on supporting information and Medicare guidelines is met
• Advise appeal requestors of next best actions
• Provide guidance of appeal process
• Send appeals to second level in appeal process per Medicare guidelines
• Create new and review open prescription appeal requests
• Educate appeal requestor of Medicare/Medicaid guidelines that must be met for appeal approval
• Document denial and approval information within the appeals
• Communicate with doctors, nurses, pharmacist to provide medical records, clinicals and all information that will support the appeal requests
• Request and approve Appointment of Representative Form(AOR form) Power of Attorney and other documents that are required in order to process the appeal
• Review members plan benefits, dates of service, eligibility Evidence of Coverage and services provided to process appeal accurately
• Initiate all grievances from Medicare beneficiaries
• Assist Providers/Specialists, members/family and Pharmacist with appeal process
• Process appeals for medications, skilled nursing facilities durable medical equipment and transportation
• Resolution Specialist
• Advise and help resolve customer service advocates inquiries and issues by providing job aids and by identifying the plan member's needs such as benefits, eligibility, claims and appeal outcome
• Help guide and educate customer service advocates with fundamentals and benefits information to better assist the plan members
• Provide customer service advocates assistance with reviewing members Medicare billing inquiries, enrollments, disenrollments dispute and refund requests, to maximize the value of their health plan benefits and to choose quality care providers
• Provide guidance for customer service advocates when contacting care providers on behalf of the plan member to assist with appointment scheduling, referrals, Prior- Authorizations, billing and connections with approved specialists.
• Assist customer service advocates in navigating UnitedHealth Group websites and tools to assist customer needs effectively
• Medicare/Medicaid /DNSP/SNP Medicare Advantage Plans
• Medical and prescription Claims
• Coordination of Benefits resolution
• Data entry
• Problem solving
Real Estate Agent
Independent contractor - Houston, TX
August 2018 to Present
• Develop a marketing plan for clients to attract and address the needs of buyers
• Identify properties for sale through multiple listing services and present them to clients
• Assist clients as they explore financial options
• Gather client information in regards to features in a home, financial ability,home types and neighborhoods of interest
• Present offers to clients
• Preside over negotiations and advise clients on suitable courses of action Operations Assistant
NRG ENERGY - Houston, TX
January 2007 to September 2017
Accounts Payable Specialist
• Exercise knowledge of power plant operation
• Create Service Entries
• Data entry
• Vendor account management
• Genetal ledger reconciliation
• Reduce and resolve duplicate and overpayments.
• Match and enter bill of ladings
• Freight/logistics disbursements.
• Liaison for managers, engineers and clients
• Facilitates meetings with various departments and suppliers to streamline processes and provide root cause analysis
• Obtain DOA approval for invoices
• Research and Resolve invoice issues
• Code Non PO invoices
• Process biweekly payroll for 100 plus employees
• Enter timesheets for bargaining unit employees
• New hire onboarding in SuccessFactors, I9 & e Verify
• Review overtime report
• Obtain vacation, overtime and PTO approvals
• Participate in payroll close
• Investigate and resolve payroll issues
• Enter and update direct deposit information.
• Purchasing Buyer
• Create service and material Purchase Orders
• Create RFQs
• Create and manage blanket purchase orders
• Obtain quotes and negotiate pricing for cost effective savings for materials, chemicals, repairs and equipment rentals
• Purchase of gas turbine parts and services
• Responsible for inventory control and management
• Participate in annual inventory audits / cycle counts
• Prepare bid specification orders
• Assist with sales transactions tax audits
• Prepare monthly and annual plant budget reports
• Manage and create journal entries
• Present budget reports in monthly metrics meetings.
• Review monthly tax report for errors
• Send corrections to tax department for refund of overpaid taxes
• Journal entries
• Prepare spreadsheet to report cost savings that will impact plant budget monthly based on tax analysis
• Assist tax department with preparation of filing tax refunds Billing Coordinator
Parkway Hospital Houston - Houston, TX
February 2006 to April 2010
• Assisted patients with insurance forms and claims.
• Perform billing tasks
• Ensure Insurance claims were billed correctly to the insurance companies.
• Post payments to patient accounts
• Review and post daily cash balances
• Assign accounts in Collections queues for follow up
• resolutions: appeals and denials
• Perform Customer Services calls in a timely manner
• Obtain insurance approvals and prior authorizations in a timely manner
• Notify patients in advance of out- of -pocket expenses prior to services rendered
• Complete and submit insurance claims
Education
License in Real Estate Sales
Champions School of Real Estate - Houston, TX
2018 to 2018
Certificate in Train the Trainer
San Jacinto Community College - Houston, TX
2015 to 2015
Diploma in Medical Assistant
Allied Health Careers - Austin, TX
1993 to 1994
High school diploma or GED
Skills
• ACCOUNTING (10+ years)
• ACCOUNTS PAYABLE (10+ years)
• AUDITS (10+ years)
• BUDGET (10+ years)
• BUYING/PROCUREMENT (10+ years)
• Microsoft Office
• Human Resources Administration (8 years)
• Payroll
• Scheduling
• Real Estate
• Hiring
• SAP
• Maximo
• SAP SuccessFactors
• Alzheimer's Care
• PeopleSoft
• Accounts Receivable
• Root Cause Analysis
• General ledger reconciliation (9 years)
• JD Edwards
• Office Management
• SOX
• Purchasing
• Journal Entries
• Account Reconciliation
• Medical Billing
• Hospice Care
• SharePoint
• Management
• Medical collection
• Analysis skills
• Typing
• Tax Experience
• Bank Reconciliation
• QuickBooks
• Manufacturing
• Presentation skills
• ERP systems
• Data collection
• Windows
• HIPAA
• Customer service
• Kronos (6 years)
• Benefits administration
• SAP CRM
• Microsoft Access
• EDI
• Process improvement
• Phone etiquette
• Communication skills
• ICD-10 (3 years)
• ICD-9 (5 years)
• IVR (6 years)
• CPT coding (6 years)
• UKG (2 years)
• Accounts payable
• Microsoft Excel
• Accounting
• Microsoft Office
• Data entry
• Time management
• Communication skills
• General ledger reconciliation
• Account reconciliation
• General ledger accounting
• Bookkeeping
• Accounts receivable
• Payroll
• JD Edwards
• ERP systems
• Tax experience
• PeopleSoft
• Kronos
• SAP
• Analysis skills
• Budgeting
• Oracle
• EDI
• CRM software
• Purchasing
• SAP ERP
• Office management
• Typing
• SAP CRM
• Procurement
• Customer service
• SharePoint
• Front desk
• Oil & gas
• Manufacturing
• Adobe Acrobat
• Windows
• Maximo
• ServiceNow
• Presentation skills
• Leadership
• Supervising experience
• Direct sales
• ICD-10
• Cash register
• Visio
• Conflict management
• Root cause analysis
• IVR
• Continuous improvement
• Human resources
• Expense management
• Microsoft Access
• Store management
• QuickBooks
• Childcare
• HIPAA
• HRIS
• Governmental accounting
• ICD coding
• Documentation review
• Construction
• Administrative experience
• Negotiation
• ADP
• Medical administrative support
• Home health
• Marketing
• Google Docs
• Team management
• Sage
• Order fulfillment
• LMS
• Retail sales
• Computer literacy
• Microsoft Outlook
• Microsoft Word
• Computer skills
• Operations management
• Order entry
• Medical terminology
• Sales
• Document management
• ICD-9
• Logistics
• 10 key typing
• Customer support
• Caregiving
• Medication administration
• Resident's rights
• Senior care
• Hospitality
• DocuSign
• Microsoft Powerpoint
• Data collection
• Computer networking
• Account management
• Pivot tables
• Train the Trainer Certification
• Data entry
• Microsoft Office
• Computer skills
Certifications and Licenses
Medical Assistant
Present
BLS Certification
Assessments
Customer focus & orientation — Proficient
July 2021
Responding to customer situations with sensitivity Full results: Proficient
Work style: Reliability — Proficient
May 2023
Tendency to be reliable, dependable, and act with integrity at work Full results: Proficient
Bookkeeping — Proficient
November 2023
Calculating and determining the accuracy of financial data Full results: Proficient
Protecting patient privacy — Proficient
May 2022
Understanding privacy rules and regulations associated with patient records Full results: Proficient
Sales skills — Proficient
September 2020
Influencing and negotiating with customers
Full results: Proficient
Managing accounts in QuickBooks — Proficient
November 2023
Using QuickBooks software to manage business financials Full results: Proficient
Warehouse safety — Proficient
May 2023
Using safe practices in a warehouse setting
Full results: Proficient
Medical receptionist skills — Proficient
June 2023
Managing physician schedules and maintaining accurate patient records Full results: Proficient
Call center customer service — Proficient
June 2021
Demonstrating customer service skills in a call center setting Full results: Proficient
Attention to detail — Proficient
May 2023
Identifying differences in materials, following instructions, and detecting details among distracting information
Full results: Proficient
Medical billing — Proficient
May 2022
Understanding the procedures and forms used for medical billing 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
PROFESSIONAL SKILLS
Proficient in: Microsoft Word, Excel, PowerPoint, Word Perfect, SAP, ADP, PeopleSoft, Quickbooks, Maximo, Medisoft, JD Edwards, Full Cycle Accounting: Accounts Payable, Accounts Receivable, Cash Applications, Budget Analysis,
Journal Entries, Data Entry, Payroll Processing, New Hire Onboarding, warehouse audits, Success Factors, Bargaining Unit experience, logistics support, Medical Insurance Billing, PBX/Switchboard Operation, dispatching, 10-Key, Excellent Team Player, Detail Oriented, Strong Oral & Communication Skills, Sales, Purchasing, Insurance Verification, Scanning, chat/ email support, First Aid & CPR Certified, CD-9 & CPT Coding, Home Health Care: Hospice, Medicare Specialist, HIPAA, Dementia and Alzheimer's, Phlebotomy, Health Insurance Advocate, Medical Assistant,Courier/Delivery driver
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