Research Specialist Resolution

Stephanie Blount

**** ***** **** ****** • Omaha, NE 68104 • Stephanie.Blount@gmail,com • 402-***-****

Summary

Highly personable professional with several years of extensive experience in the pharmacy benefits management industry. My experience includes providing great customer service, supervising personnel, account management and claims data analysis. In addition to developing and cultivating relationships with various clients to conduct business and resolve issues in order to provide quality service.

Experience

Claims Technical Analyst

Prime Therapeutics

December 2012 – Present) Omaha, Nebraska

I am currently responsible for providing subject matter expertise related to pharmacy claims processing. Leveraged knowledge of pharmacy claims data, adjudication logic, claims reporting, and experience with complex problem solving in order to support ongoing and project work related to Commercial and Medicare lines of business.

Functional subject matter expert for claim processing system changes. Ensuring business requirements are complete and correct. Working with cross-functional teams to ensure that claims adjudicate according to business requirements by creating user acceptance and regression testing scenarios

Assess the impact of claim processing system defects or setup errors. Provide leadership in performing detailed claims impact analysis.

Research and provide insight into existing claim adjudication system functionality or claim processing outcomes.

Facilitate collection of reporting requirements and create standard or customized reports via SAS or ad hoc query tool.

Participate in training to keep claims processing knowledge up to date and assist with training and mentoring new hires.

Run audit assistance related to claims data requests and other duties as assigned.

Administer, balance and authorize payment of HMO claims.

Conduct investigations to adjudicate claim/error reports and initiate adjustments for claims.

Evaluate appealed claims and make necessary adjustments to establish proper benefit administration.

Determine eligibility for manual claims and run vendor and internal error reports.

Account Specialist

Prime Therapeutics

October 2006 – December 2012 (6 years, 2 months) Omaha, Nebraska

I was responsible for researching escalated issues, communicating with members and clients, and providing administrative support. In addition to meeting established service levels, member expectations and supporting implementations.

Provided clients, members and pharmacies (Government Programs) with information regarding benefit plans to assure accurate claims processing and client/member satisfaction research

Utilized Prime’s internal systems to reply to questions and escalated issues from Prime’s internal and external partners in a timely manner and escalated issues as appropriate

Communicated issue resolution results per standard operating procedures in a timely manner

Served as a subject matter expert (SME) and mentor, assisting with technical questions, workflow or process direction

Collaborated with the supervisor to identify process and/or quality improvement opportunities and assist in the implementation of solutions

Assisted leadership with various projects as the need arose

Collaborated with and responded to external clients and prepared / completed client reports as needed.

I was chosen to handle High Priority groups as a direct contact to insure business continuity

Traveled to North Carolina and Florida to assist with initial implementation

Senior Service Agent: Seasonal Positions

Prime Therapeutics

September 2004 – October 2006 (2 years 1 month) Omaha, Nebraska

In my position as a Senior Service Agent I was selected to fill multiple seasonal roles to assist with the workload during peak season. I was also chosen to supervise personnel on several special projects to assist with Prime’s business needs.

Paper Claims Supervisor – Supervised small team of agents to who assisted with processing and reviewing Medicare paper claims

Resolution Specialist – Worked on dedicated call line taking escalated calls from Prime members to resolve their issues

Pharmacy Agent – I was responsible for providing pharmacies with information regarding benefits plan (co-payment, deductible, quantity and day supply limitations and assisting with claim adjudication.

Research Specialist – Handled and resolved member

Senior Service Agent

Prime Therapeutics

September 2003 – September 2004 (1 year) Omaha, Nebraska

I was responsible for supporting the Member Service Agents by taking escalated calls from Prime members that needed special handling to complete benefit inquires.

Acted as backup for inquires that cannot be resolved by Member Service Agents and escalate issues that can’t be resolved.

Maintained knowledge of multi-channel process to include plan benefit information, phone and computer databases and customer service skills.

Coordinated with other departments (Pharmacy Operations, Benefit Plans, etc.) for further investigation and resolution of inquiries.

complaints by phone or written correspondence

Member Service Agent

Prime Therapeutics

December 2003 – September 2003 (8 months) Omaha, Nebraska

I was responsible for handling incoming calls in accordance with department standards and other verbal and written training memorandums. I provided this service with a positive and proactive approach to ensure that the member issues were resolved the first time in a professional and caring manner within a Contact Call Center environment.

Cultivated customer trust by providing members and pharmacies with accurate information regarding benefit plans to assure member and client satisfaction and accurate claims processing

Investigated and resolved phone inquiries in a timely manner and also forwarded escalated calls as needed to Senior Service Agents or Supervisors

Processed member pharmacy refill requests, prescription renewals and placed outbound calls as needed regarding member benefits while maintaining professional and courteous communication resulting in high call quality

Education & Certification

Institute of Computer Science – Omaha, Nebraska

Certificate of Completion in Computer Applications

1983 – 1985

Northwest High School – Omaha, Nebraska

College Prep Studies

1978 – 1982

Training

Advanced Courses in Microsoft Excel 2003, PowerPoint 2003 and Outlook 2003

Medical Terminology

Conflict Resolution Course

Time Management and Prioritizing Course

Lotus Notes

AS400

Ad Hoc Query

Interests/Memberships

Child and Family Development Corporation – Member

Boys & Girls Club – Omaha, NE – Volunteer

Girls Inc. – Omaha, NE - Volunteer

United Way Committee – Prime Representative

Prime Walk to Wellness – Participant

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