Quality Assurance Service Representative
Resume:
Najionah Parker
Philadelphia, PA 19140
**********@*****.***
Skills:
I am a highly skilled and experienced professional with a diverse background in the healthcare industry. I am experienced in: Degreed Accounting (Auditing); and Business Operations and General Business. WithWith a strong focus on quality assurance and attention to detail, I have excelled in roles such as Plan Automations Analyst, Provider Claims Service Representative, and Client Set Up QA Analyst. Based in Philadelphia, PA, I am seeking opportunities in the healthcare industry, particularly in roles that involve claims processing, quality assurance, plan automations and pharmacy operations. With proficiency in Microsoft Excel, Word, and various analytical tools, I bring strong problem-solving and analytical skills to any organization. Additionally, I hold a Pharmacy Technician License and possesses in-depth knowledge of Medicare and pharmacy operations.
Experience
June 2024 - November 2024
Independence Blue Cross, Philadelphia, PA (Hybrid Contract) - Client Set Up QA Analyst
● Participates in pre and post implementation audits of client benefits and setup.
● Healthcare compliance
● Keeping up-to-date on changes in healthcare regulations and industry best practices
● Maintaining detailed records of compliance activities and submitting reports to regulatory agencies when necessary
● Identifying and managing potential conflicts of interest among healthcare providers
● OPTUM RX claims testing quality review
● Prepares accurate and complete claims test scenarios.
● Performs comprehensive group setup audits to validate setup accuracy and/or compliance issues to ensure quality setup for clients. 2
● Responsible for reviewing claims and systems to validate benefit setup accuracy for Medical products including Ancillary Setup as required
● Effectively document and review audit results to ensure benefits are compliant with set up requirements and Client’s contracted benefits.
● Assist Configuration team with building of benefit plans.
● Review and adjust insurance policies.
● Evaluate client details to assess risk levels.
● Make recommendations on changes to insurance needs.
● Use computer software to evaluate insurance policies to determine the risks for a policyholder and an insurance company
July 2023- May 2024
The Cigna Group, Philadelphia, PA (Remote) - Plan Automations Analyst
● Conduct initial and final validation of platform, client portal and census, as needed
● Healthcare compliance
● Protecting patient health information
● Ensuring accurate and compliant billing procedures
● Maintaining proper documentation of patient care
● Configure new clients and inforce client changes in the platform
● Collaborate with resources to ensure issues are addressed and corrected prior to production completion
● Timely completion of all required deadlines
● Auditing of all medical plans
● Peer audit review
● Properly communicate and document any known delays
● Partner with team members and matrix partners to meet team and organization goals
● Consistently meet all defined deadlines and metrics in regards to the overall implementation and change process Provide consistent service by responding to matrix partner inquiries and delivering on commitments 3
● Develop and maintain strong relationships with critical matrix partners to provide support for retention and growth opportunities
● Continue to develop understanding of overall implementation process while working to improve existing process and procedures
● Identify and find ways to refine the overall implementation process, sharing these findings to help develop best practices
● Show continued improvement month over month in key areas of job functionality
● Support department and organization projects, including migration activities November 2022- May 2023
Amerihealth Caritas PA, Philadelphia PA(Remote) - Provider Claims Service Representative
● Responds to and resolves provider and health plan claim inquiries.
● Process/reprocess claims as needed.
● Monitors and tracks aged, pended, and open reports to maintain timeliness in claims processing
● Claims auditing.
● Inputs claims into the system for appropriate tracking and processing.
● Documents files as appropriate to support payment decision. August 2022- November 2022
Pfizer, Collegeville, PA - Pharmacy Services Representative
● Manage customer orders and inquiries by serving as the initial point of contact for customer telephone calls, consistent with product or brand specific requirements
● ensuring that prescriptions are correct and appropriate for patients
● Dispensing medications
● filling and labeling medications that doctors have prescribed to patients
● Advising patients about their medications, including side effects, drug interactions, and dosages
● Maintain a detailed working knowledge of Pfizer trade policies, SOPs, and standard business processes in order to respond to customer and sales force inquiries regarding the Pfizer Trade Policy, Return Policy, shipping practices, invoice terms, product availability information
● Handle customer contacts in a professional, diplomatic, and empathetic manner, as defined in quality monitoring guidelines
● Redirect callers who require assistance from other departments 4
January 2022-July 2022
PharmaSource, Philadelphia, PA - Pharmacy Technician
● Accurately prepare and distribute patient medications;
● Perform calculations
● Collect accurate patient information
● Process third party billing claims and assist with prior authorization completion;
● Work directly with patients to obtain medication histories and reconciliation;
● Assist in the management of investigational drug studies;
● Use technology to help maintain accurate patient records, medication inventory, and orders, and;
● Ensure compliance with regulatory requirements
May 2019– February 2021 Willis Towers Watson, Mt.
Laurel, New Jersey - Benefits Representative (temp to hire)
● Supports customers by providing helpful information, answering questions, and responding to complaints.
● Medical plan audit review
● Researching and analyzing healthcare plans, including medical, dental, vision and disability insurance.
● Assisting employees by explaining benefits and appealing decisions made by insurance companies.
September 2018 - May 2019
GreenDrop LLC, Bensalem, PA - Call Center Agent
● Obtains client information by answering telephone calls; interviewing clients; verifying information. Determines eligibility by comparing client information to requirements.
● Informs clients by explaining procedures; answering questions; providing information.
● Accomplishes sales and organization mission by completing related results as needed. Maintain call center database by entering information. February 2018 - September 2018
365 Health Services, Philadelphia, PA - Direct Care Worker
● Assisting individuals with their daily living, provided safety, and comfort, providing assistance to people with basic tasks such as bathing, dressing, grooming and eating, and helping with home management tasks such as preparing meals, grocery shopping, and cleaning.
January 2017 - February 2018
Moravia Health, Philadelphia, PA - Home Health Aide
● Supporting patients by providing housekeeping and laundry services; preparing and serving meals and snacks; and running errands, and providing personal services, such as, bathing, dressing and grooming.
5
Education
June 2012 – June 2015
Commonwealth Connections Academy, Philadelphia, PA – High School Diploma
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