Call Center Customer Service
Resume:
Daytha Johnson
********@*****.***
SUMMARY PROFESSIONAL:
• 7+ years of experience working in Administrative/Clinical positions performing various duties
• Experience working in the healthcare field entering data into systems and filing claims
• Worked in a fast-paced call center environment answering inbound calls from customers and logging calls
POSITION SUMMARY:
Fortuna BMC / Gainwell Technologies-Remote:
Medicare/Medicaid Call Center Agent: 07/2024 – 11/2024
Inbound customer service either in government or private sector settings.
Medical call center agent working remotely
Call Volume of 35 calls a day
Handle incoming calls, address customers or provider inquiries, or escalate them to the appropriate channels.
Process calls efficiently to meet or surpass performance metrics
Maintain meticulous call records, process requests, and ensure accurate documentation of account history.
Collaborate with team members, management, and customers to resolve customer service issues effectively.
Providing Health Benefit Information to Members within the Wisconsin County Consortia
Familiarity with basic help desk software, computer applications, and Microsoft Office suite.
EOB: Explanation of Benefits with Members.
Verification of Benefits to Provider Line
Explanations for Denials, Reasons for Claims
Able to Understand claims Process denials information
dedicated phone line where individuals can contact trained representatives to receive information,
answer questions, and resolve issues related to their Medicare health insurance coverage, including billing inquiries, plan selection, benefit details, and general medical concerns, often operated by the Centers for Medicare and Medicaid Services (CMS) or a contracted service provider.
CVS Health (e-Teams): 08/2023 – 07/2024
Coverage Determination Representative II
Utilizing multiple software systems to complete Medicare Prior Authorization case reviews
Experience Knowledge on ICD-10-CM, Procedure codes, Modifiers, diagnosis codes
Meeting or exceeding government mandated timelines
Complying with turnaround time, productivity, and quality standards
reviewing and verifying insurance claims submitted by Providers
Ensuring accuracy and completeness of information, determining policy coverage
Processing claims payments according to company guidelines,
While adhering to relevant regulations and communicating with policyholders regarding their claim’s status
Conveying resolution to beneficiary or provider via direct communication and professional correspondence
Acquiring and maintaining basic knowledge of relevant and changing Med D guidance
Data entry and navigating multiple computer applications while utilizing two screens is the primary function of job (possible outbound calls needed). A job history demonstrating this is recommended.
Pharmacy or medical background is preferred.
Successfully worked independently in a data entry, productivity driven role is preferred.
Required Qualifications:
Critical thinker/problem solver
Receptive to constructive feedback and flexibility in adapting to change
Ability to effectively plan, prioritize, and organize time and workload
Ability to execute successfully in a deadline-oriented, fast-paced, highly regulated environment
Ability to sit at desk/station and focus on reviews for entire shift
Proficient in navigation of multiple computer applications
Utilizing multiple software systems to complete Medicare appeals case reviews
Meeting or exceeding government mandated timelines
Conveying resolution to beneficiary or provider via direct communication and professional correspondence
Acquiring and maintaining basic knowledge of relevant and changing Med D guidance
work closely with providers to process prior authorization (PA) and drug benefit exception requests for multiple clients or lines of business and in accordance with Medicare Part D CMS
Regulations. Must apply information provided through multiple channels to the plan criteria defined through work instruction.
Research and conduct outreach via phone to request providers to obtain additional information to process coverage requests and complete all necessary actions to close cases.
Responsible for research and correction of any issues found in the overall process.
Phone assistance is required to initiate and/or resolve coverage requests.
Escalate issues to Coverage Determinations and Appeals Learning Advocates and management team as needed.
UnitedHealth Care/Group/Optum 360:
Clinical Administrative Coordinator: 02/2022 to 06/2023
Outlining the reasons for the denial based on the policy terms and providing information on how to appeal the decision if the policyholder disagrees with the outcome.
5+ years of experience working with ICD-9 / 10 and CPT codes Experience working with Microsoft Word (creating, editing, saving documents) and Microsoft Excel (creating, editing, saving spreadsheets)
Experience working with a PC and windows applications, with the ability to learn other sometimes complex systems/MS Chat
Any experience working within the healthcare industry.
Working knowledge of medical terminology
Required to have a dedicated work area established that is separated from other living areas and provides information privacy.
Ability to keep all company sensitive documents secure (if applicable)
NLT (National Letter Team): Following strict company Guidelines: setting up letters to be sent out to Member's, Provider's, and other facilities for denials of treatment.
toggle though 3(three) computers
research when needed.
continuous contact with team leaders and supervisors.
very close attention for detail/ claim processing for denial letters
continuous training
100% Remote
Cor-Tech: (CVS Healthcare): 04/2021 to 10/2021
Specialty Prior Auth Agent:
Review Medical Records meticulously examines patient records to determine if treatments, procedures, or medications require prior authorization, ensuring that each case is assessed accurately
Insurance Verification confirms patient insurance details, verifying that the coverage is in place for the proposed healthcare services. This involves a deep understanding of various insurance plans and their coverage details
Authorization Requests responsible for preparing and submitting detailed authorization requests to insurance companies, complete with all necessary documentation
Collaboration works closely with healthcare providers to collect necessary clinical information, streamlining the authorization process.
Monitoring and Follow-ups follow up with insurance companies and keep detailed records of all communications.
Denial Management investigates insurance denials, resubmit requests, and appeal when needed to ensure that patients receive the care they require
Stricter criteria stringent guidelines and require extensive documentation to support the need for the medication
Analyzing detailed medical records and clinical information to assess the medical necessity of a requested specialty treatment or medication, Clinical Review.
Self-Management/ Self Organized
Processing Claims for Approval and denials / Per criteria.
Ability to toggle between computers systems.
Research information while on Inbound calls/ and Outbound calls
Knowledge of Medical terminology/ ICD codes
Virtual meetings/ Toggle between screens
Specialty Medication Intake agent:
Electronic Faxing medical information
Documentation review/ Medical chart notes
Strong communication skills with (ALL) medical staff/ dispensing Pharmacies
Prior Authorization for Specialty medications
Aetna/CVS Caremark:
Overrides/ Medical math on dosage
Verification of NPI’s,
High attention to Privacy/ HIPPA Self-Management:
Deloitte-Fortuna BMC- Position: 01/2021-05/2021
Information Technician Call Center:
●Under Client EDD- Provide unemployment insurance claims information
●Processing applications / Claims Processing
●Verification of eligibility based on employment history
●Utilizing EDD computer system to access claimant information, update claim status and process transactions.
●Able to always deal with Escalated situations.
●Self-Management, Time Management, Fast learner,
●Conducting Phone Interviews
●Able to research for information.
●Multi-task, able to toggle through Computer systems, Multiple Screens.
●EDD (Employment Development Dept), New York State Vaccine Hotline
●Keeping track with adherence
●Answering at least 50 or more calls a day.
●Use to sitting for long periods of time,
●Very good at working in close-off, quiet areas
●Access to Confidential records Information with help in processing claims
Travis Credit Union,: Vacaville, Ca ( on-site)
Call Center Teller: 06/2019 – 01/2020
●Primarily interacts with phone calls in a Call Center environment with an emphasis on performing answering questions,
●Resolving issues related to accounts, any Transactions and Services
●Promoting cross-selling opportunities for TCU products and services
●Inquiries on account balances, recent transactions, loan payments, interest rates
●Processing requests like address changes, transferring funds, setting up automatic payments, check ordering
●Investigating and addressing concerns regarding account discrepancies, billing errors, fraudulent activity
●Understands the importance of, and works towards, achieving the credit union’s short- and long-term strategic plans.
●Understands the importance of schedule adherence and the role it plays in maintaining the Call Center’s service objectives.
●Able to manage escalated calls without assistants.
●Wire Transfers,
Walgreens, Vallejo, Ca October 2018 to 03/2019
Shift Lead:
Obtains and maintains valid PTCB certification or pharmacy license as required by the state.
Complete product returns, order voids, customer refunds, cash drops to the safe, and provide change as requested to cash registers.
Maintain positive working relationships with direct reports, peers, vendors, union officials, and corporate office personnel.
Open and close of store, / (Work in a 24-hour store)
Prioritize, plan and coordinate work activities for the entire staff using effective time management skills.
Manage and track store financial performance, inventory safety, customer service and management of entire staff.
Assign Task delegate task and workloads to team members
Plan workflow changeovers
Faneuil (Covered California) Sacramento, California 11/2017 to 03/ 2018
Healthcare Call Center:
•Answering calls from potential and current Covered Ca customers regarding health insurance plans and coverage options, premiums, and eligibility
•Helping customers to select appropriate plans based on their needs and income
•assisting with completing necessary paperwork
•Verification for Covered CA plans, (Income, residency, and potential individuals that may qualify for Medi-Cal
Provider detailed explanation of health insurance terms, benefits, and plan features
Troubleshooting issues related to billing, claims, plans changes
•Implemented solutions and escalated unresolved problems
•Staying updated on Covered CA policies and regulations, ensuring accurate information is provided to customers.
•First Line of Contact
Xerox (CompNova): Sacramento, California: 10/2014 – 03-2015
Medi-Cal Claims Specialist:
•Primarily answer calls from Provider enrolled in the Medi-Cal program
•Medi-Cal questions on billing, Claims, denials, eligibility verification, provider Enrollment
•Check writes for Providers for Paid claims
•Understanding claim submission guidelines
•Procedure code, Modifiers, ICD-9, ICD-10 Knowledge
•Navigations: Medi-Cal site: Provider Portal: Medi-Cal billing support affiliated healthcare Programs and claims
•Guiding Providers through enrollment process/ necessary documentation required
•Details related to issues with electronic health records (EHR)/ use for Medi-Cal billing
• Communicated patient eligibility and explaining benefit coverage details
• Informed customers about the services available and assessed customer needs
• Often requiring them to navigate complex healthcare regulations and internal systems to resolve issues.
Walmart Pharmacy, Richmond, Ca: 02/2014 to 05/2014
Pharmacy Technician/Clerk:
Data entry patient information, prescription details, and medication dispensing records into pharmacy systems of Prior authorizations Knowledge of Medical terminology and prescription abbreviations
Attention to detail and accuracy in medication handling, Filling Prescriptions
Checking stock levels, ordering medications, rotating stock, maintaining proper storage conditions
Record keeping, Prepare pharmacy Reports
Understanding drug interactions and side effects
• Processing insurance claims, verification of coverage, resolving billing issues
• Ensured fulfillment of pharmacy prescriptions, maintained, and tracked medication inventory
• Maintained automated medication counting machines, processed insurance: rejection claims
• Explained medications, knowledge of generic to brand name forms of medications
• adhering pharmacy regulations, including proper handling of controlled substances and medication safety procedures.
Blue Shield of California (K Force): 08/2013 to 012 2014
Pharmacy Call Center Consultant:
•Must hold a valid pharmacy technician license in the state of practice
•Receiving calls from patients, doctors, and insurance companies regarding prescription orders, refills, frug interactions, and billing questions
•Resolved outpatient pharmacy benefit coverage (inclusion/exclusion), prescription claim problems
•Ability to analyze pharmacy/patient inquiries, identify issues, and provide appropriate solutions
•Confirming patient demographics, insurance details, and prescription information ensure accuracy.
•Entering prescription data into pharmacy database checking for drug interactions, and processing insurance claims
•Explaining insurance coverage, copays, and medication eligibility
•Routing complex issues to pharmacists for further consultation when necessary
•Communicated drug formulary guidelines including drug formulary alternatives, prior authorization criteria and group/member eligibility problems
•Adhering to HIPAA regulations regarding patient privacy and confidentiality
Safeway Pharmacies: 10/ 2012 to March 2013
Pharmacy Technician/Clerk Floater:
• Provided superior customer service, set up fills, and maintained pharmacy display cases
• Keen knowledge of working with Medicare and knowledge of waiting for prior authorizations on medications
• Faxed doctors for refills, e-scripts faxing to doctors, medication self pulls, out dates checking, put up order when it came in, fill new prescriptions,
• Heavy phone calls throughout the day working alongside the pharmacist answering questions from patients
Pelsten Group: 06/2012 to 11/ 2012
Medical Records Representative/ Abstractor:
• Position held at Contra Costa regional medical building
• Converted medical information from the old (EMR/EHR) Electronic Medical Health Records system, onto new EPIC system
• Knowledge of computers and medical terminology
• Transcribed doctor's notes from charts, very high in knowledge of medications and data entry
Summarizes patient records to help improve patient care.
Find specific medications/medical information in patient records
Ensure records meet quality standards.
Analyze records for trends to improve care.
Collaborate with other healthcare professionals to provide recommendations on ways to improve patient care.
Deer Park Pharmacy (Pride Staff): 09/2010 to 03 2011
Pharmacy Technician/Clerk:
• Heavy phone lines, under supervision of the pharmacist
• On the phones with different insurance companies
• Computer knowledge of how to adjust patient profiles for medicine, and label making, customer service, filling prescriptions, taking in new prescriptions, inventory plus, ordering of medicine every day, stocking of medicine and OTC (Over the counter).
Kaiser Permanente: October 2004 to July 2009
Outpatient/Inpatient Pharmacy Technician
• Under supervision and control of a licensed pharmacist, provided in-person, and telephone reception
• Submitted required reports, mixed medicine, ordered medicine for stock and for patients
• Working knowledge of aseptic technique, preparing sterile IV products, knowledge of drug dosage forms, strengths, knowledge of generic and trade names
• Proficiency in the pharmacy computer system, read, understand, and transcribe pharmaceutical information, learning chemotherapeutic agents transcribe, abbreviated, and symbolized information from physician's order into patient medication profile
EDUCATION:
Silicon Valley College, Walnut Creek, California- Vocational School: 09/2002 – 04/2004
AAPC Online Classes- Self-paced: Medical billing and coding: 06/2023 Certification (Pending Until finished)
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