Call Center Customer Service

Kevin Gerard Stokes

*** ******* ****** ** 919-***-****

Knightdale, NC 27545

Job Objective Dedicated experienced professional with project management and customer service skills including:

● 10+ years of high volume call center experience

● Problem solving/understand procedures

● Organized and detail oriented

● Self/team management

● Strong skills in time management

Experience

REIMBURSEMENT SPECIALIST (Nov. 2023-May. 2025)

Johnson & Johnson, Raleigh NC

I reviewed and completed benefit investigations with the Escalation Department. My duties included contacting providers and patients to verify information to complete the patient services process. I served as a shadower/trainer to assist with newer agents to show day to day activities. Conducted Zoom calls to demonstrate a complete overview of the Patient Service process. Consistently showed excellent Quality and Assurance.

● Maintain frequent phone contact with payers to gather all necessary information related to case/patient information, insurance coverage, and where applicable, prior authorization (PA) or appeals processing.

● Serve as operational expert on payer trends, product access, and reporting reimbursement insights and/or delays, i.e., denials, underpayment, access delays.

● Leverages both electronic and telephonic benefit investigation tools to verify eligibility, coverage, authorization and appeal process, specialty pharmacy mandates, and cost differences.

PROVIDER CLAIMS SERVICE REPRESENTATIVE (Nov. 2021-Nov. 2023) Amerihealth Caritas NC, Raleigh NC

Reviews and adjudicates claims based on provider and health plan contractual agreements and claim processing guidelines. Serves as a subject matter expert, conducts cross training to staff as required, demonstrates solid knowledge of provider service/claim systems, functions and team procees. Demonstrates superior skills in dealing with provider issues/inquiries, team members and coworkers

● Suspends claims requiring additional information and/or special handling; initiates action to obtain required information

● Forwards claims requiring external departments interventions to the appropriate department or person

● Monitors outstanding inquiries and works with management staff to identify and resolve areas of non compliance

● Reviews and verifies quality audit reports

● Reconciles audit discrepancies, corrects in system and make appropriate change to avoid recurrence

● Maintains thorough knowledge of claims process systems, its database and subsystems REIMBURSEMENT SPECIALIST (Jan. 2018-Nov 2021)

TrailCard, Raleigh NC

Responsible for handling day-to-day activities for an end-to-end patient support program.

● Complete medical and/or pharmacy benefit investigations, identify and facilitate submission of required documentation for payer/plan review for prior authorization, step edit identification and appeals according to program standards operating procedures

● Knowledge and understanding of the different types of major payers including private/commercial and government (medicare, medcaid VA, DoD)

● Partner with patient care coordinator to serve as an advocate to patients and healthcare professionals regarding insurance coverage, medical billing, reimbursement process, and general access for pharmaceuticals

● Maintain high level of ethical conduct regarding confidentiality and privacy MEDICAL COLLECTION ADMINISTRATOR II (July 2017-Oct 2017) Mednax, Raleigh NC

The Medical Collections Administrator II is responsible for effective and efficient accounts receivable management of assigned payors. The collections efforts on outstanding accounts includes: telephone contact with payers as well as patients, working high volume collection reports and correspondence,auditing accounts, appealing denied claims as necessary, updating accounts as needed, identifying carrier related denial trends and consistently meeting departmental productivity standards

● Ensures that claims are processed accurately through review and audit functions to ensure timely payment. Responds to inquiries regarding claims with under payment or non payment

● Maintained working knowledge and understanding of CPT and ICD-10 codes. Keeps current with healthcare practices and laws and regulations related to claims collection through participation and professional development activities

● Prepares routine management reports, quality reports, and special reports as directed by supervisor

CALL CENTER ASSOCIATE (Nov. 2015-March 2016)

Artech, Durham NC

Assist client using cutting edge science to discover, develop, manufacture and market biological products for the treatment of serious diseases

● Answer inbound calls and made outgoing calls to MS patients

● Setup trail shipments of medications and follow up on lost shipments

● Collected data on patients and advise events

● Demonstrated strong and interpersonal skills providing patient and healthcare provider support

BENEFITS SERVICE CENTER SPECIALIST/PRIOR AUTHORIZATION REPRESENTATIVE

(Nov.2011-Feb 2014)

ACS, Cary NC

Provides support for incoming calls from Aetna members and doctors regarding prescriptions

● Gathers information, research/resolves inquiries and log customer calls

● Responds to telephone inquiries and complaints using procedures

● Verify and approved prior authorization on medications for Aetna members

● Provides functional guidance, training and assistance to lower level staff

● Communicates appropriate options for resolution in a timely manner

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