Customer Service Claims Representative
Resume:
Zorina Adams
Urgently looking for work.
Antelope, CA 95843
******@*******.***
Professional Summary
Authorized to work in the US for any employer
Authorized to work in the US for any employer
Work Experience
Claims Representative/adjuster
UnitedHealth Group-CA
April 2024 to Present
• Claim processing
• Claim adjustments
• Pended claims
• Paying claims
• Releasing
• Maintained a high level of productivity while meeting quality standards in processing a large volume of claims daily
Customer Service Advocate (Remote)
UnitedHealthcare-Sacramento, CA
April 2023 to Present
• Answering incoming phone calls from, members, providers, facilities etc and answer questions about benefit and eligibility, billing and payments, authorizations for treatment, explanation of benefits, and claims information both HMO and PPO plans.
• Research complex issues across multiple databases and work with support resources to resolve customer issues or partner with others to resolve escalated issues
• Create an emotional connection with members by understanding and engaging .
• Taking accountability to fully understand the member’s needs by building a trusting and caring relationship with the member.
• Anticipate customer needs.
• Advocate for members
• Review of member claim history to ensure accurate tracking of benefit maximums and/or coinsurance. Investigating claims and sending them for necessary adjustments (if any)
• Review member’s benefits and copays
• Advise members on their Preauthorization status
• Review claims, medical, dental, prescriptions
• Bill payments
• File appeals.
• File grievance
• Pharmacy formulary, track orders, drug prices, explain tiers, file CD.
• Advise on RX benefits, tiers and coverage stages. SKILLS
• Basic computer skills.
• Fact finding skills
• Retail sales and customer service experience .
• Excellent communication .
• Effective problem solving skills.
• Strong organizational and time management skills.
• Multi tasking through multiple programs.
• Critical thinking and quick resolution skills.
In Home Caregiver
Crown Point Villa-Roseville, CA
November 2020 to Present
• Provided compassionate and personalized in-home care for individuals with varying health conditions and needs, ensuring their physical and emotional well-being
• Administered medications according to prescribed schedules, adhering to all safety protocols and maintaining accurate medication records
• Assisted clients with activities of daily living (ADLs), including bathing, dressing, grooming, and mobility support, promoting independence and maintaining dignity
• Monitored clients' vital signs and reported any changes or concerns to healthcare professionals, contributing to early detection and intervention
• Assisted with mobility devices, such as walkers or wheelchairs, ensuring clients' safety and independence in navigating their living spaces
• Responded to emergencies calmly and efficiently, following established protocols and seeking assistance when needed
• Facilitated communication between clients, family members, and healthcare providers, ensuring a collaborative approach to care
Customer Service Claims rep/fact finder(REMOTE)
Randstad/Maximus,Remote( Employment Development Department)-Sacramento, CA January 2022 to February 2023
Customer service/call center (Remote)
Demonstrated ability to be empathetic and
Compassionate
Patience
Good listening
Adaptability.
Basic computer, typing and telephony skills
Work any schedule.
Data entry.
Follow company policy and rules.
Fact finding on pending issues on claims..Assist the California Employment Development Department in auditing claimant certification weeks for potential discrepancies and benefit overpayments. Review and audit a claimant's potential overpayment status based on complex financial information by evaluating wages and earnings.
Interviewed claimants to gather pertinent information. Process claims with confirmed eligibility issues for potential adjudication/determination by EDD. Document findings, along with actions taken to supplement case notes. Collaborate with subject matter experts to address unique issues. Multi tasking.
Typing
Critical thinking
Decision making
Organizational skills
Problem solving skills
• Follow HIPAA,PII.
• Retrieving customer data and up dating information.
• Handle emails, inbound calls, and outbound calls
• Assisted claimants with a warm and professional attitude. TECHICAL PROFICIENCY
• sharepoint, smartsheets, office 365 Microsoft Teams, Excel, AWS,NICE/IEX, OTECH,Virtual contact center(vcc), Field glass, zoom, multiple systems login utilizing different multi-factor authentication applications,3270 HHSDC Session.
Pharmacy Technician/Cashier
Walgreens Pharmacy-Sacramento, CA
September 2021 to February 2023
Prepares prescriptions and distribute drugs under the pharmacist and supervisor. Resolve insurance issues if any.
Healthcare info update.
Data Entry.
Sales
Maintaining good Customer service
Type prescriptions
Fax Prescribers for new refills
Do Covid tests
Inventory up keep and maintaining patients confidentiality. Filling patient’s prescriptions.
Teller/customer rep cash handling.
Assisting customers with applying for new services. Maintain positive attitude all day.
Effective listening .
Team player.
Answer calls and customers inquiries and needs with empathy . Paying attention to detail by listening and being organized . Medtech
Carlton Senior Living-Sacramento, CA
November 2018 to March 2020
Administering medication,ordering for refills,organizing the med cart and keeping residents meds in order,keeping residents information private,providing necessary information to family members when asked and if any concern raising regarding their loved ones,taking vitals,reporting to the in charge nurse,receiving outbound calls,faxes and general office duties. Medtech.
Franklin Heights Nursing and Rehabilitation Center-El Paso, TX June 2018 to November 2018
Medication Aide,assisting residents with their medications, updating residents’ families and Doctors of any changes in residents, taking vitals,reports to the in charge nurse for any changes in patients,charting,ordering for refills, looking out for expiration dates. CNA/Medication Tech
University village memory care and assisted living-Round Rock, TX April 2017 to May 2018
Caring for people in need of care(all kinds) I.e grooming,toileting,transferring,interacting,engaging in games and passing medication
Nanny
Preety Badesha-Round Rock, TX
August 2015 to March 2017
Taking care of baby.
Caregiver/Manager
Blue Garnet personal care home-Marietta, GA
March 2013 to July 2015
Caring for the elderly,grooming,toileting,feeding,games,,passing meds,charting and taking vitals, Answering calls, faxing.
Documenting patients information and care, Sales.
Bank Teller/Customer Service Representative
Crane Bank Ltd-Kampala, Uganda
June 2005 to November 2012
cashing checks,banking customers money,helping customers with any inquiries,receiving out bound calls and making inbound calls,assisting customers in the most professional way with their inquiries. Front Desk Receptionist
Deluxe holiday inn-Kampala, Uganda
February 2002 to April 2004
Checking customers in and out,booking hotel reservations,records of room availability,post charges for room,food,telephone,assist customers with any of their needs pertaining their stay at the motel. Education
Associate's degree in Airfares and ticketing
Airways Tourism and hotel institute - Kampala, UG
January 1998 to October 2000
High school diploma or GED in Geography, literature in English, economics. St James Senior secondary school - Kampala, Uganda March 1995 to May 1997
Alevel in Arts subjects
Stella Maris college Nsube - Mukono, Uganda
February 1991 to November 1994
Skills
• Typing
• Microsoft Excel
• Telephony
• Dementia Care
• Authentication (2 years)
• customer service,front desk (10+ years)
• Cash register
• HIPAA
• Reception
• Microsoft SharePoint
• Computer literacy
• Home Care
• Medical terminology
• Childcare
• Customer service
• Cash handling
• Patient Care (6 years)
• Order entry
• Windows
• Dementia care
• Vital signs
• Insurance verification (2 years)
• AWS
• Data collection
• Guest Service
• Customer Service (10+ years)
• Customer support (10+ years)
• CNA/CMA (4 years)
• Home health
• Nursing
• Senior Care
• Senior care
• Time management
• Documentation review
• Medical terminology (6 years)
• Home care
• Front Desk
• Live chat
• Caregiving
• Memory Care
• Microsoft Office
• Pharmacy technician experience
• Medication Administration
• Front desk
• Microsoft Word
• CMA (3 years)
Certifications and Licenses
BLS Certification
Pharmacy Intern License
Certified Medication Aide
CNA
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