Customer Service Representative
Resume:
Tambla S. Birkheimer
Massillon, Ohio *****
**********@*****.***
Professional Experience Summary
Escalation Manger Medicare & Retirement in Government Operations remote
Medicare, Medicaid, Dual Special Needs, Family Advisor, High-Risk Navigator, Navigator. Tier I and Tier II Customer Service Representative.
Group Insurance Administrator, Medicare Audits, DME, Radiology billing, Benefits Administrator
Ohio Medicaid Consumer hotline
Paid Volunteer Coordinator Habitat for Humanity
Protective Service Representative/Case Manager/Advocate
Mentoring Director, University of Rio Grande, Rio Grande Community College
Ad Executive, Marketing Assistant
United Healthcare 06/2017 – 5/2025
Escalation Manager, Medicare and Retirement, Government Operations Telecommuter 9/2025 – 05/2025
Highest escalation level under corporate office taking inbound calls from corporate office switchboard and all government relations areas, customer service, leads, supervisors, agents, providers, dedicated corporate representatives, skilled nursing facilities, rehab facilities, corporate retiree groups.
Handle and escalated and abusive callers and deescalate the situation and troubleshoot Medicare, Medicaid, DSNP, CSNP, ISNP, Medicare Advantage, PDP and corporate groups, delegated physician groups insurance plans.
Identify all account issues and satisfactorily resolve the problem in any areas of benefits for healthcare, pharmacy, prior authorizations, credentialing, dental, vision, behavioral health, enrollment, disenrollment, grievances, special program benefits, over the counter, rewards, claims, premiums, late enrollment penalties, fitness and wellness benefits, transportation, materials, pharmacy, etc.
May involve providing internal assistance to supervisors or customer service representatives to take direction to assist them with assisting their caller or may require call to be conferenced directly to me to further assist.
Achievement: Able to earn bonus for outstanding quality work and received several Bravo Diamond Awards
Sr. Tier II High-Risk inbound/then Navigator outbound Telecommuter 5/2022 – 9/2025
Assist assigned panel of members with Medicare Advantage plans and coordinate care with providers, schedule appointments, identify gaps in care and present next best actions as appears on members accounts. Answer questions regarding benefits specific to members plan and may also coordinate care for post-hospital discharge needs and assist with approvals for rehabilitation, skilled or unskilled nursing. Assist members with prescription coverages. Troubleshoot and/or deescalate any issues member is having and correct problems or rout to appropriate area to fully resolve member issues with the goal as first call resolution. At time I am pulled from this line of business to assist other lines of business such as group or a segment of members that have received letters to assist with business needs in other areas.
Achievements: Consistently meet metrics on quality and performance.
Benefit Advocate (Tier I M&R Government Operations) Telecommuter 2019 - 2022
Inbound calls regarding MAOM line of business for members Medicare plans including DSNP and CSNP plans Troubleshoot member account issues and take appropriate actions to correct the problem and provide first call resolution. Took overflow calls from other areas besides upper Midwest to include calls throughout the United States. Answer questions regarding benefits specific to members plan and may also coordinate care for post hospital discharge needs assist approvals for rehabilitation, skilled or unskilled nursing, occupational therapy, physical therapy, and any needed DME adaptative equipment. Assist members with prescription coverages.
Achievements: Consistently met metrics on quality and performance.
UHC - Special Needs Family Advisor Telecommuter (Corporate) Telecommuter 2018
Provided benefit information and advocacy for approval for children with special needs. This position required the aptitude to be proactive, organized, resourceful and relentless with solving issues and provided proactive support to parents of special needs children who may have special needs themselves. Worked with nursing under Medical Director to ensure unique complex medical issues are being individually considered with medical decision approvals. Referred various UHC programs of supportive services meeting the individualized needs of the member.
Achievement: My previous supervisor recommended this position for me to apply because of the skill set I have and the creative ability and determination and passion I have and demonstrate.
Tier II CSR (C&S Medicare, DNSP, Medicaid) Westerville and Dublin, OH 2/2017 – 2018
Inbound call center taking member calls regarding benefits for medical, dental, vision for Medicare, DSNP, CSNP plans with goal of fist call resolution. Troubleshoot any account issues and take appropriate actions to resolve issues. Took overflow calls for United States. Advocate members to participate in wellness activities. Worked with Facets, Maces, Optum Rx Unix systems, VCC phone system.
Achievements: Consistently able to be a top performer.
UHC - Tier I Medicaid Customer Service Rep (C&S) Westerville, OH 6/2017 – 2/2017
Inbound call center with first call resolution. Troubleshoot any account issues. Answer benefits questions regarding a variety of different states Medicaid programs as benefits can vary from state-to-state.
Achievements: Directly promoted to C&S Tier II Rep six months after hired, Won awards for excellent Customer Service, assisted with new hire floor support, consistently obtained bonus. Also served on UHG LEET Team and assisted with event planning and employee morale building activities.
EDUCATION
Bachelor’s degree in communication (emphasis in public relations)
University of Rio Grande, Rio Grande, Ohio
Public Relations Internship University of Rio Grande
Personally, selected by Dean of Social Sciences then Dr. Barbara Hatfield
Edited and updated faculty and division webpages
Wrote recruiting publication, including photography, for the School of Social Sciences.
Published by the University of Rio Grande and Rio Grande Community College
SIGNIFICANT COLLEGE ACHIEVEMENTS
Student Body Vice-President, University of Rio Grande
Served five terms as an elected Student Senator, also held Senate Secretary position.
Chair of Rio Student Mentoring and able to double membership each academic year.
Assisted in grant writing and mentoring organization incorporated into a retention grant awarded.
Appointed by university as lobbyist with the State of Ohio for higher education funding.
National Dean’s List
PROFESSIONAL EXPERIENCE PRIOR TO UNITED HEALTHCARE
HKT Teleservices, Dublin, OH 01/2017 - 2017
Customer Service Representative, serviced Airbnb
Handled international vacation booking reservations, destination add-on excursions and payments.
Properly addressed any complaints and provide alternative destination or if appropriate gave customer compensation.
Contact law enforcement if needed regarding lock outs, not being able to find booked address, and/or neighborhood complaints with noise or other complaint issues.
Achievements: Able to achieve bonus immediately out of training
Advocate Radiology, Powell, OH 06/2016 - 1/2017
Radiology Biller
Nationwide radiology billing.
Inbound calls from insurance companies, attorneys, patients regarding claims and billing for radiology services.
Posted accounts receivable in computer and refunds.
Troubleshoot customer account issues and take appropriate action to correct issues.
Molina Healthcare, Columbus, OH 11/2015 - 04/2016
Claims Analyst (Apple One Contractor)
Routed claims in QNXT system
Renamed and sorted computer files.
Did special projects as assigned.
Appointed to CERF claim reconsiderations, followed up with providers on status of appeals. Assisted with UMR projects.
Scanned, faxed, and assigned documentation number to incoming and outgoing documentation.
Achievements: Assisted handicapped worker with mailroom office work and contract extended three times before laid off.
Vision Service Plan (VSP), Columbus, OH 07/2014 - 12/2014
Customer Account Representative (InnoSource, Contractor)
Inbound call center for providers/doctors, members, and corporate accounts.
Corporate enrollments loading employees and activating their plans.
Verified eligibility, copays, and vision benefits.
Troubleshoot account issues and claims.
Resolved complaints and determine adequate compensation.
Achievements: Completed all levels of training and contributed to VSP’s achievement of World Class Call Center certification through JD Power and Associates.
Automated Health Systems (Medicaid Consumer Hotline), Columbus, OH 01/2014 - 6/2014
Customer Service Representative
Inbound call center did enrollments for Medicaid into Obama Care, Medicaid plans, My Care Ohio plans.
Community agency resource referrals.
Verified eligibility through State of Ohio computer systems.
Achievements: Provided clarification to management so consumers better understood programs and benefits.
Advocacy & Protective Services, Inc. (APSI), Columbus, OH 03/2008 - 08/2013
Protective Service Representative, Case Manager, Advocate, on call crisis line
Probate Court-appointed guardian for informed medical consent with caseload of 60 to 75 individuals with developmental disabilities, autism, and some dual-diagnosed with mental illness.
Maintained a high level of confidentiality and followed all HIPAA and Medicare billing Title XX regulations.
Completed Court required annual Guardian reports specific to consumes county.
Conducted quarterly in person visits in home, day program, work, supported living and waiver homes, nursing home facilities, hospitals, or hospice facilities.
Completed medical chart review and requested specific orders as related to patient.
Conducted meetings with medical staff on as needed basis. If necessary for health and safety restricted visitations.
Investigated incidents as a mandator reporter and informed County Boards of DD of MUI (Major Unusual Incidents). Contacted law enforcement when appropriate.
Made recommendations regarding DNR/code status requested by physicians and reported findings to physician and home office and compiled DNR agreement or disagreement with physician reports.
Coordinated organ and tissue donations.
Processed admissions, plan of care, discharge meetings and paperwork.
Made appropriate recommendations for alternative medical treatments and or second opinions.
On-call every two-week rotation for management of office and to handle crises calls, gave informed medical consent for treatment, surgery, mental health facilities admissions.
Reviewed, edited, and approved behavioral support plans to be implemented.
Achievements: Trained provider staff on complex behavior support plans and how to do documentation tracking. Obtained approval from Judge/Magistrate for Individualized Service Plan and Behavior Support plans to be incorporated as part of probation terms, which had never been done before in Franklin County Courts. Able to meet different expectations of two supervisors simultaneously. Serviced on Human Rights Committees for Columbus Developmental Center (CDC) and Alvis House.
Habitat for Humanity, Greater Columbus area 8/2007 – 2008
Paid Volunteer Coordinator, Project management, Supervision
Managed and in charge of volunteer orientations, various events, corporate volunteering, groups and individual volunteers.
Project management for corporate groups, individuals, interns, school groups.
Recruiting, scheduling volunteers for events and booth staffing for events and Ohio State Fair.
Updated member database.
Served as guest speaker at various venues.
Build-site-photographer.
Designed volunteer training programs and in charge of monthly held Volunteer Orientation events.
Achievements: Able to increase corporate volunteer event donations by 70 percent. Obtained approval with Franklin County Workforce Development through Job and Family Services for volunteer participation where work was required for their benefits. Created Tuesday and Thursday evening builds.
Additional Professional Experience
Valpak and Ad Works Direct, Akron and Cleveland, Ohio
Ad Account Executive
Over five years as an Ad Account Executive
Outbound calls, prospecting businesses
Developed advertising, marketing, and publicity campaigns, and lead generation tracking systems.
Wrote Ad copy, designed logos and presentation materials for Trade Shows
Attended trade shows and networking functions
Achievements: Able to have repeat customers and obtain yearly contracts from various businesses.
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