Healthcare Industry
Resume:
Phyllisia Weeks
*** ******* ***** ********** ** *5214
********@*******.***
Federal Basic Clearance
Professional Summary
Dynamic, self-motivated professional with years of experience in Customer service, claims, EOB, Provider/Facility Network Management role, such as provider data management, credentialing, and/or provider services. Negotiates and also develops and maintains excellent relationships with hospital and health system providers. Experience with primary and secondary payers. Leveraging solid interpersonal communication and decision-making skills to assess healthcare claims to obtain entitled benefits under federal, state, and local legislation.
Expert in offering exceptional customer service, providing strategic recommendations by defining issues, establishing facts, and drawing conclusions to surpass customer expectations.
Capable of operating in a fast-paced environment and establishing operational initiatives to meet goals and on-time.
Employment History
Name of Company: HEOPS, Inc
Job Title: Contract/Network Development Manager
Location: Remote-Birmingham, AL
Dates of Employment: Nov 20, 2022 –Current
•Leads contracting and network development, ensuring network adequacy through reimbursement methodologies, credentialing, and provider relations. Delivers the expertise necessary in ensuring network development, network participation, credentialing accuracy, timeliness, thoroughness, and completion.
•Functions as liaison and maintains a strong relationship amongst the health plan and its partners, such as hospitals, specialists, IPA groups, DME providers, home health providers, mental health vendors, and laboratories.
•Provider Relations leader who develops provider networks, excelling in operational analysis and developing solutions for process inefficiencies.
•Credentialing experience in managed care organizationand medical group organization
•Produces and designs duties for recruitment, contracting, and retention of providers and facilities.
Proficient in MIPS, MSSP, value based and bundled payments. Experience with accessing reports and analyzing provid data.
Credentialing qualified doctors, hospitals, facilities, and providers in order to maintain an eligible, cost effective network across several states.
Name of Company: Aetna Insurance
Job Title: Customer Service Health Advocate
Location: Work From Home-Birmingham, AL
Dates of Employment: Jan 10, 2022 – June 10, 2022
•Follow up on pre-authorizations, financial assistance and appeals processes within Aetna’s platform
•Handles Customer inquiries that are of basic and at times complex nature.
• Engages, consults and educates members based upon the member’s unique needs, preferences and understanding of Aetna plans, tools and resources to help guide the members along a clear path to care.
• Answers questions and resolves issues based on phone calls/letters from members, providers, and plan sponsors. Train on PPO, HMO, Traditional Choice and HNO plan
• Triages resulting rework to appropriate staff. Working with Evicore, formerly Medsolutions
• Documents and tracks credentialing for doctors, providers includingmedical groups.
• Guides the member through their members plan of benefits, Aetna policy and procedures as well as having knowledge of resources to comply with any regulatory guidelines.
• Creates an emotional connection with our members by understanding and engaging the member to the fullest to champion for our members' best health.
• Taking accountability to fully understand the member’s needs by building a trusting and caring relationship with the member and provider.
• Anticipates customer and provider needs, assists with denials and follow-ups.
• Provides the customer with related information to answer the unasked questions, e.g. additional plan details, benefit plan details, member self-service tools, etc.
• Uses customer service threshold framework to make financial decisions to resolve member issues.
• Explains member's rights and responsibilities in accordance with contract.
• Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) via target system.
• Educates providers on our self-service options; Assists providers with credentialing and re-credentialing issues.
• Responds to requests received from Aetna's Law Document Center regarding litigation; lawsuits.
• Handles extensive file review requests, perform random audits of case loads
• Assists in preparation of complaint trend reports.
• Assists in compiling claim data for customer audits with basic knowledge of procedure and diagnosis codes (ICD-9 and ICD-10)
• 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. Uses applicable system tools and resources to produce quality letters and spreadsheets in response to inquiries received.
Experience with Google suite of tools to include Google sheets, google doc, google form etc
Knowledge of online calendars and scheduling using Google Calendar
Excellent phone, email and instant messaging communication skills
Knowledge and experience of remote working policies and procedures
Name of Company: Social Security Administration
Job Title: Team Lead - Claims Coordinator
Location: 1200 Rev Abraham Woods Jr Blvd. Birmingham, AL 35243
Dates of Employment: May 5, 2014– Nov 20, 2021
Deliver technical support to Customer Service Representatives as well as providing leadership and advice to guarantee uniformity, including appropriate application of Social Security Administration rules, policies, and procedures while supporting management authorities in completing the unit's tasks.
Provide feedback and reports to team members on audit results
Analyze information on training needs to build recommendations to minimize errors and improve process performance
Responsible for quality assurance for trainees and journeyman
Train new hires on Avaya
Highlighted Contribution and Achievements:
Manage, train, and mentor staff with assertive leadership, advanced communication skills, and authoritative knowledge. Empower and support the team via employee selection, development, mentoring calls, and performance management.
Process Social Security and Medicare claims
Process claims for state programs including Medicaid and Medicare Part D for prescription
Explain EOB and coordination of benefits
Conduct inquiries and interviews to obtain, clarify and verify information about beneficiaries, including claimants' initial along with continuing eligibility for programs administered by SSA.
Provide broad knowledge of services available to the elderly, blind, disabled, and other claimants/beneficiaries from local, federal, state government agencies and private agencies to enhance SSA-administered programs or otherwise benefit the public.
Monitor and audit department's workload for successful metrics
Perform random audits
Responsible for quality control on claims and request transactions
Reliable, responsive, and empathic to counterparts possess cooperative working relationships while reviewing work besides providing advice, assistance, and training to the Customer Service Representative while also ensuring approachability along with availability to offer the greatest possible technical support.
Research and analyze data from multiple sources as well as databases to determine status, payment history, investigate information, or make inputs to resolve or process a wide variety of claims, including post-entitlement actions and develop the effective use of SSA services.
Review garnishments and bankruptcy documentation for debt management due to overpayments
Received a Commissioner's Exceptional Customer Service Award in 2018
Experience with Google suite of tools to include Google sheets, google doc, google form etc
Knowledge of online calendars and scheduling using Google Calendar
Excellent phone, email and instant messaging communication skills
Knowledge and experience of remote working policies and procedures
Name of Company: BBVA Compass Bank
Job Title: Mortgage Loan Processor III (Triage)
Location: Birmingham, AL
Dates of Employment: November 2010– April 2014
Circumspectly processed as well as reviewed home mortgage loans, communicated efficiently with branch representatives and customers daily, ensuring accuracy and completeness of documentation.
Highlighted Contributions and Achievements:
Successfully met mortgage loan operational standards by adding mortgage loan information to strategic plans and reviews and creating credit reports.
Processed re-disclosure and RESPA Change circumstances, assessed LTV and debt ratios before presenting to upper management.
Critically reviewed bank statements enquired about large deposits, secured interest rates, and change programs.
Name of Company: BB&T, (formerly Colonial Bank)
Job Title: Appraisal Coordinator
Location: Birmingham, AL
Dates of Employment: Jan 2008- Nov 2010
Accurately maintained appraisal database, assisted appraisers in revaluating assets and preparing financial reports, noted assets purchased as well as sold in-between two appraisals, and troubleshooting appraisal orders.
Highlighted Contributions and Achievements:
Maintain workflow efficiency by effectively resolving immediate and personal customer service problems by tracking progress, receiving appraisals, and responding to all issues.
Managed, prioritize, and coordinated caseload of appraisal orders on a complex property while meeting team goals.
Assessed and analyzed information to complete Requests for Proposals, generate as well as maintained Excel spreadsheets, and contacted field appraisers daily to assure accurate appraisals.
Communicated and explained the progress to customers through establishing relationships while also developing a solid rapport with our internal and external vendors.
Education
Graduate work towards Master of Science in Management School/University Birmingham, AL
Bachelor of Arts in Business Administration Faulkner University Birmingham, AL
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