Customer Service Behavioral Health

Janelle J. Spector

** ***** ***** **** ****** CT, 06514 ***********@*****.*** 203-***-****

Profile

I am a team player that is always willing to help and always strive to go beyond expectations. I have strong interpersonal and communication skills proven through the ability to work with minimal supervision. I have taken on leadership roles throughout my career and have a compassion for my skillsets and the industry in which I work for. I can carry out the assigned tasks that I receive in a timely and efficient manner to be an exceptional representation of the company and industry in which I work for. I have coordinated and prioritized several duties throughout my career that have always been customer focused. I work closely with my colleagues and customers to find solutions to investigate and resolve more complex issues when needed to implement improvements for the products and services that are provided. I have extensive experience with claims, resolving customer complaints for both internal and external customers. I am proficient in the use of MS office programs and other portals and software that have been provided throughout my career. I am a customer focused and company focused professional, and I care dearly about my career and how we as a team contribute to the customer base in which we represent and support.

Core Skills

۰Detail Oriented ۰Mature Judgement ۰Problem Solving

۰Self- Starter ۰Social Perceptiveness ۰Leadership

۰Customer Service ۰Strategic Planning ۰Critical Thinking

Professional Experience

Northern Illinois Recovery

Utilization Review Specialist Remote, CT

Reviews applications for patient admission and approves admission or refers case to

facility utilization review committee for review and course of action when case fails to

meet admission standards.

● Compares medical records to established criteria and confers with medical and nursing

personnel and other clinical professional staff to determine legitimacy of treatment and

length of stay.

● Abstracts data from records and maintains statistics.

● Determines patient review dates according to established diagnostic criteria.

● May assist review committee in planning and holding federally mandated quality

assurance reviews.

Contacts Insurance Care Managers as scheduled to perform Utilization Review status

discussions

● Analyzes client insurance policies and understand limits of benefits on

behalf of clients and advocate for the client’s care with care managers

Arranges with Medical Director in the event of a peer-to-peer evaluation of a client’s

care.

● Works closely with billing and Accounts Receivable regarding client accounts and

covered services

Anthem Blue Cross and Blue Shield

Implementation Specialist Remote, CT

2021-Present

Talks with customers via phone, e-mail or in person to ensure the best service possible.

Review of new client enrollment material for accuracy through the contract review process.

Responds to incoming calls/e-mails and may initiate outgoing calls or meetings to provide customer service to brokers and employer groups by answering benefit questions, resolving issues, and educating callers to company policies.

Verifies enrollment statuses, makes changes to records, research, and resolve enrollment system rejections.

Address a variety of enrollment questions or concerns received by phone, email, or online meetings.

Strong attention to detail to accurately enter data and research.

Posts new firms, rates and benefit changes to Enrollment and Billing.

Processes new firm installations, benefit conversions, product additions, terminations, and mergers.

Anthem Blue Cross and Blue Shield Wallingford, CT Autism Team for Behavioral Health/Utilization Management Rep III 2016-2021

Reviews and requests for ABA Services.

Provides guidance and assistance to healthcare members with finding the best care for their families.

Utilizes skill set to work complex cases to provide resolutions in a timely manner.

Establishes standard Job Aids and work procedures for the entire department.

Supports healthcare members via phone and email with information regarding Autism and therapy when needed.

Collaborates with Clinicians to obtain authorizations.

Prepares and executes internal training for team members.

Assists leadership teams in decision making of corporate procedures.

Extensive Knowledge of protocol and procedures for Behavioral Health Unit

Reviews processes and research IFO and Single Case Agreement Requests for all states

Responsible for retrieving incoming faxes and email and processing reports according to AUMSI guidelines for each managed State.

Acts as liaison between Medical Management and internal departments in accordance with company policy.

Verifies benefits and eligibility information through the contract review processes set forth by the company’s Quality Management System.

Extensive knowledge of health plans including familiarity with prior authorization and pre-certification process.

Resolve diverse and complex inquiries/situations through advanced analytical skills and problem solving.

Anthem Blue Cross and Blue Shield Wallingford, CT

Utilization Management Rep II 2007-2016

Responsible for retrieving incoming customer communication and processing reports according to AUMSI guidelines for each managed state.

Referred cases to Clinical Staff for contract review.

Acted as liaison between Medical Management and various internal departments.

Responded to inquiries from clients, providers, and in-house departments.

Conducted clinical screening processes per company procedures and FDA guidelines.

Extensive knowledge of health plans including familiarity with prior authorization and precertification processes.

Worked on problems of a diverse scope where analysis of data required evaluation of identifiable factors through problem solving and team involve.

Resolved diverse and complex inquiries/situations through advanced analytical skills and problem solving.

Authorized sessions for outpatient behavioral health treatment to providers.

Ability to multitask while being detail oriented and processing effective reports to support the services in which I represent.

Conducted training for new employees.

Anthem Blue Cross and Blue Shield Wallingford, CT

Customer Service Representative 2005-2007

Consistently maintained contact with clients for resolution of complaints and issues.

Efficiently answered telephone calls within ASA standards for Public Sector/State of Connecticut Accounts.

Resolved complex situations through advanced problem-solving techniques with collaborative leadership groups.

Worked with in-house departments to assist clients in answering any question and getting the help they need.

Education

Albertus Magnus College ۰ New Haven, CT

Bachelor of Arts۰Psychology

Completed May, 2014

Master’s Degree- Human Services, Post University

Presently pursuing

Graduate Certification in Alcohol and Drug Counseling,

Post University

Presently pursuing

Contact this candidate