Service Representative Member Services

ABOUT ME

Accomplished Bilingual Member Services Coordinator with extensive experience in leading a team by example, coaching, HMO, PPO, Claims, Ten Key, Billing, and Processing. Contributed to various projects that ensured prompt client responses by case managers.

EXPERIENCE EDUCATION

Watterson College AA- Certified Travel and Tourism 1985 - 1986

Birmingham High School High School Diploma 1981 - 1984

Work Experience

Centene

Health Net Appeals and Grievance Coordinate 12/2022-04/2023

Assist in the monitoring of medical services to assure cost effective use of medical resources through processing prior authorizations, Initiate authorization requests for outpatient and inpatient services in accordance with the prior authorization list, verify eligibility and benefits. Performed office duties such as answering phones, process faxes within established standards, and entering authorization data into the system.

MedPoint Management

CIU (Claims Inquiry Unit) Representative 03/2020-04/2021

Sustaining facility operations and customer inquiries as well as managing company-assigned projects. Facility operations include answering and screening a large influx of phone calls, handling re-directions, claims, eligibility, and follow-ups. Consulted with various case managers to ensure the prompt response to client inquiries.

Regal Medical Group

Member Services Coordinator 10/2018-12/2019

Sustaining facility operations and customer inquiries as well as managing company-assigned projects. Facility operations include answering and screening a large influx of phone calls, scheduling, handling re-directions, claims, eligibility, and follow-ups. Consulted with various case managers to ensure the prompt response to client inquiries.

SAG-AFTRA Health Plan

Participant Service Representative 06/2016-08/2018

Operator with high volume phone inquiries regarding benefits, claims, status, eligibility, pensions, premiums, and earnings. Request applicable correspondences for providers and participants, such as for benefits, eligibility, pre-authorizations, and order of benefits. Handling CRM contacts, and effectively executing requests from providers, participants, and management.

Anthem Blue Cross

Senior Customer Services Rep III / Provider Care Unit 02/2001-07/2014

Inbound Customer Senior Representative for Provider Care Department. Assisting with complex customer service issues. Taking supervisor calls. Mentoring and training new hires. Assisting provider’s with benefit questions, claims issues, appeals. Resolved any issues the provider had. Helped with obtaining additional help thru government agencies and other insurance agencies. Liaison for the member and other departments within the company. Trained other new hires, worked on special projects within the department. Handled any reporting, analyzing reports.

SKILLS

Customer Service

Product Knowledge

Insurance Policies

CalPERS

HIPPA Policies

Labor Laws & Regulation Compliances

High-Impact & Public Speaking

Documentation

RESPONSIBILITIES

Benefit clarification, eligibility, verification, and claim status.

Medical group/PCP provider assignments

Explanation of how the plan works and how to utilize the services

Assist with information regarding referral or authorization

Request change of provider/member information

Any complaints/grievances

Update new member eligibility on appropriate systems

Perform overrides for covered/authorized prescriptions as needed

Participate as a team player by demonstrating support to peers, management, and the department’s goals

Attend meetings and training sessions as scheduled

Assist with training new employees as needed

Show flexibility in meeting performance objectives consistent with IPA and department objectives

Document all member inquiries and complaints in appropriate systems and either handle, redirect or defer to the appropriate department for resolution.

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