TANIA L. RAMOS

**** ****** **** ***** *********, FL 34746

407-***-****

advk03@r.postjobfree.com

Key Skills Include:

Customer Service call center experienced

Telephonic skills (Inbound & Outbound calls)

Data Entry

Medical Terminology & Coding

Bookkeeping & Filing

Quality control

Benefits Management

Proficiency with Microsoft Office (Outlook, Excel and Word)

Ability to multi-task

Detail-oriented

Strong organization skills

Customer Services Quest certification

C-Proficient Spanish certification

Summary

Outstanding interpersonal skills with a track record of establishing positive relationships with customers. Demonstrated understanding and ability to articulate concerns with customers.

Objective

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.

Accomplishments:

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

Professional Experience

Aetna Inc. — Orlando, FL

Care Management Associate, 2017- Current

Key Results:

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

Key Results:

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

Education

High School Diploma, Lola Rodriguez Tio, High School — Puerto Rico

Languages:

Fluently in English and Spanish

References will be furnished upon request.

Contact this candidate