Service Representative Customer

Rhonda Weaver

**** *** ******, *******, ***** ***16

Cell: 806-***-**** • ***************@*****.***

Profile

Offering over 20 years of Health Plan experience which includes Commercial, PPO, HMO, Medicaid and Medicare. Seeking new opportunities in this field; especially interested in openings as a Customer Service Representative.

Core Strengths

•Function as a Team player or self-manager

•Quick learner

•Excellent problem solving, interpersonal and communications skills

Career Experience

Anthem, Inc. dba Amerigroup — Lubbock, Texas, Texas Nov 2014 to Feb 2022

Member Liason-Compliance/Sr, Member Advocate

•Responsible for the coordination of the Denials and Appeals process including tracking, trending, and reporting all denial/ appeals and for assuring that all regulatory, state, and contractual requirements are met.

•Responsible for providing specialized support for clinical compliance initiatives and regulatory/contractual requirements, member retention by investigation and resolution of member complaints, acting as liaison/mediator between the member, provider and Health Plan

•Function as a liaison between the Health Plan, Member Services Representatives, State Agencies, and providers regarding medical denials and appeals.

•Function as a subject matter expert for the individual team with a strong emphasis on gathering any applicable information and /or documentation to obtain resolution on Pharmacy Complaints/ Issues.

•Facilitate the members understanding of the decision and decision review process. Assist in developing and implementing departmental policy and procedures that remove barriers to customer satisfaction.

•Use superior communication skills to diffuse emotionally charged situations while maintaining rapport with the customer

•Collaborate with several departments including Underwriting, Medical Investigations,

Grievance and Appeals, Claims, Membership and Legal

•Refer issues and concems regarding members to the Case Management departments as appropriate

•Educate members and providers about Health Plan policies, programs, and services when contacts results in questions, concerns or educational needs

•Record information for management to facilitate ongoing service and quality improvements.

Firstcare Health Plans, Inc. — Lubbock, Texas May 2006 to Nov 2014

Pharmacy Services Coordinator Il

•Supported customer service in resolving member and provider prescription drug related issues.

Rhonda Weaver

6711 7th Street, Lubbock, Texas 79416

Cell: 806-***-**** • ***************@*****.***

(Continued)

•Provided solutions to Guide and educated customer service staff on prescription benefits and formulary entry issues with goal to increase first call resolution for customer services.

•Reviewed daily eligibility reports and fomearded to the appropriate internal resource for research and resolution.

•Educated customer Service staff on prescription benefits and formulary content. Responsible for communications to external vendors and Customer Services staff regarding pharmacy changes (written and verbal).

•Escalated prescription drug benefit calls to the appropriate internal or external resources.

•Coordinated internal resolution of prescription drug claims (i.e. reviewing appropriateness and resolution of rejected claims).

•Assisted clinical team with prior authorizations and Patient Assistance programs where needed.

•Placed outbound calls to the Member or physicians related to the prescription issues

•Monitor pharmacy complaints and grievances reports to ensure issues were resolved.

FirstCare Health Plans — Lubbock, Texas March 2004 to May 2006

Customer Service/Medicare Sales Representative

•Contacted potential member leads to provide the benefits of the FirstCare Health Plans Medicare Advantage policies.

•Scheduled follow up home visits to offer the Medicare Advantage to dual or non-dual potential members.

•Documented all materials that were presented at the time of the appointment to verify that the potential member understood the information that had been presented. Met monthly/quarterly goal consecutively until the Management and CEO chose to transfer all sales to a local agency.

Education

Estacado High School: Required courses, Lubbock, Texas

Associate of Science: Accounting, South Plains College - Levelland, Texas

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