TANIA L. RAMOS
**** ****** **** ***** *********, FL 34746
Key Skills Include:
Customer Service call center experienced
Telephonic skills (Inbound & Outbound calls)
Medical Terminology & Coding
Bookkeeping & Filing
Proficiency with Microsoft Office (Outlook, Excel and Word)
Ability to multi-task
Strong organization skills
Customer Services Quest certification
C-Proficient Spanish certification
Outstanding interpersonal skills with a track record of establishing positive relationships with customers. Demonstrated understanding and ability to articulate concerns with customers.
Seeking a position within a diverse organization where my adaptability, problem solving skills, strong work ethics and pharmacy knowledge will significantly contribute to the overall growth and success of the organization. To perform as a team player, leading by example and promoting the companies mission values while acting with Integrity and supporting a goal oriented work environment.
Mentored team members motivating and sharing best practices
Volunteered in special projects to achieve departmental goals
Successfully implemented innovated ideas with the supervision of upper management
Assisted to increase department revenue promoting new specialty drugs
Worked collectively with the grievance/Appeals team by referring clinical cases previously denied to launch an initial member/provider request.
Responsible of routing any new or existing clinical information to the grievance/appeal or predetermination team following Medicare guidelines
Aetna Inc. — Orlando, FL
Care Management Associate, 2017- Current
Manage daily data reports to validate utilization management of the drugs
Responsible to screen the data to mitigate members who are in a high compliance risk category
Coordinate the clinical assessment between a Registered Pharmacist and the patient
Enrolled patients who are out of compliance or have challenges filling their prescription into the program.
Interprets benefits and interfaces with members and providers to give benefit information
Maintain accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements.
Promote communication, both internally and externally to enhance effectiveness of medical management services.
Protect the confidentiality of member information and adheres to company policies regarding confidentiality
Communicate with the clinical teams (Nurses and Registered Pharmacists) when processing transactions for members active in the program.
Identifies high risk cases and alerts management.
Support the administration of the precertification process in compliance with various laws and regulations, URAQ and/or NCQA standards, where applicable, while adhering to company policy and procedures.
Support inbound/outbound calls to members & providers under the direction of Medical Management Nurses to obtain clinical information for approval of medical authorizations.
Aetna Inc. — Orlando, FL
Customer Service Associate/Help Desk, 2012-2017
Process & Call/ Reimbursement 2007-2012
Pharmacy Technician / Fulfillment 2007-2007
Associate Material Handle 2006-2007
Support inbound/outbound calls of patients who needed to request a new or existing (refill) order of their specialty drug
Lead special project for Hepatitis-C, Infertility, Multiple Sclerosis, among other specialty drugs to guarantee patient adherence with the drug treatment by prioritize the treatment cycles
Conducted non-clinical assessment with the member to collect the entire clinical picture of the patient and refer those to the clinical team
Manage all the Specialty Drugs from the National Precertification list
Triaged escalated calls from different hubs to the appropriate clinical team
Responsible to audited member’s concerns to find a positive resolution and or to provide an escalation referral to upper management
Educate medical providers of the requirements of the patient plan design and the pharmacy guidelines associated with the request
Assisted both patients and provider’s offices with any claim inquiries, claim resubmission and re-adjudication
Subject Matter Expert responsible of providing updates of imperative feedback/items from the members to the Senior Leadership when identifying challenges or problems with the internal operational process flows and assist developing innovated strategies to improve the processes and procedures within the business model.
Work independently with ease and little to no needed direction while multi-managing and spearheading projects provided by Leadership.
Provided crossed training support and mentorship to all new hires on the navigation of all systematically platforms and operational guidelines
Handles extensive file review requests. Assists in preparation of complaint trend reports. Assists in compiling claim data for customer audits.
Determines medical necessity, applicable coverage provisions and verifies member plan eligibility relating to incoming correspondence and internal referrals.
Handles incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management.
Performs review of member claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductible.
Performs financial data maintenance as necessary.
Retrieve medication from stock, count, package and label for review by pharmacist.
Retrieve medication from stock and fill automated dispensing equipment locations using proper procedures.
Fill and label prescriptions in automated dispensing systems
Assist with inventory replenishment
Remove out of date/expired medications from shelves
Receive and store incoming supplies.
Count stock and enter data in computer to maintain inventory records.
Assure accountability for all controlled drug products in accordance with good pharmacy practice guidelines.
Participate in regularly scheduled weekly cycle and physical inventory counts
High School Diploma, Lola Rodriguez Tio, High School — Puerto Rico
Fluently in English and Spanish
References will be furnished upon request.