Healthcare Specialists
Resume:
DAYTHA JOHNSON
Fairfield, ***** California
********@*****.***
PROFESSIONAL SUMMARY
Detail-oriented and compassionate Medicare/Medicaid Call Center Agent with over a decade of experience in healthcare administration and claims processing. Skilled in Medicare and Medicaid claims adjudication, insurance verification, ICD-10 and CPT coding, and prior authorization procedures. Adept at providing exceptional customer service while maintaining strict adherence to HIPAA compliance and privacy standards. Proficient in medical terminology, data entry, and Microsoft Office to enhance workflow efficiency and ensure accurate documentation. Strong problem-solving abilities, committed to improving patient satisfaction and outcomes through effective communication, timely issue resolution, and attention to detail. Experienced in managing remote work environments and handling high call volumes, contributing to operational success and client satisfaction. SKILLS
Customer Service Excellence
Problem Solving
Effective Communication
Conflict Resolution
Time Management
Attention to Detail
Adaptability
HIPAA Compliance
Prior Authorization Procedures
Insurance Verification
Medical Terminology
Medical Records Management
ICD-10 Coding
CPT Code Application
Claims Adjudication
Data Entry Accuracy
Healthcare Knowledge
Microsoft Office Proficiency
Remote Work Efficiency
Medicare Processing
Medicaid Claims Processing
WORK EXPERIENCE
FORTUNA BMC / GAINWELL TECHNOLOGIES
Medicare/Medicaid Call Center Agent 07/2024 to 11/2024
Responded to high-volume inquiries with professionalism and accuracy, achieving a 95%+ first-call resolution rate across Medicare/Medicaid cases.
Educated beneficiaries on eligibility, coverage options, and claim processes, enhancing client understanding and satisfaction.
Documented detailed call logs and account updates in CRM systems, ensuring regulatory compliance and operational transparency.
Resolved escalated concerns by collaborating with internal departments, improving issue resolution time by 20%.
Analyzed member feedback and service trends to identify process gaps, contributing to workflow optimizations that improved call efficiency.
CVS HEALTH (E-TEAMS)
Coverage Determination Representative II 08/2023 to 07/2024
Processed complex Medicare Part D coverage determinations with 100% compliance to CMS regulations and company policy.
Investigated insurance claim discrepancies, reducing processing delays by identifying and resolving coding or eligibility issues.
Delivered timely and accurate communication to providers and members, maintaining high customer satisfaction scores.
Applied ICD-10-CM coding knowledge to support accurate claim adjudication and minimize rework rates.
Collaborated with internal departments to streamline case handling procedures, boosting case throughput by 15%.
UNITEDHEALTH CARE/GROUP/OPTUM 360
Clinical Administrative Coordinator 02/2022 to 06/2023
Analyzed and processed medical claims using ICD-10/CPT codes to ensure claim accuracy and timely resolution.
Drafted clear and compliant denial communications, supporting appeals processes while ensuring adherence to payer policies.
Coordinated with the National Letter Team to optimize workflow efficiency and enhance denial letter accuracy.
Maintained full HIPAA compliance, securing sensitive medical documentation and upholding strict privacy protocols.
Managed remote operational systems, ensuring seamless communication, secure data handling, and consistent productivity.
COR-TECH (CVS HEALTHCARE)
Specialty Prior Auth Agent 04/2021 to 10/2021
Verified complex insurance details to minimize authorization errors and enhance operational efficiency.
Coordinated with providers to obtain detailed clinical documentation, accelerating approval timelines.
Evaluated medical records to determine coverage eligibility, ensuring compliance with policy guidelines.
Implemented structured workflows for prior authorizations, reducing processing delays and improving accuracy.
Improved patient satisfaction by securing timely approvals and delivering clear communication on coverage outcomes.
DELOITTE-FORTUNA BMC
Call Center Work From Home Agent 01/2021 to 05/2021
Handled 50+ inbound calls daily, accurately processing unemployment claims and verifying eligibility through EDD systems.
Resolved escalated client issues efficiently, maintaining high levels of customer satisfaction and first-call resolution rates.
Conducted structured phone interviews to validate claimant information, ensuring compliance with unemployment insurance guidelines.
Demonstrated strong multitasking and self-management in a remote setting, meeting performance benchmarks under minimal supervision.
Streamlined claims processing workflows by navigating multiple platforms simultaneously, improving accuracy and reducing handling times.
TRAVIS CREDIT UNION
Vacaville, CA
Call Center Teller 06/2019 to 01/2020
Delivered prompt resolution to account inquiries and transaction issues, ensuring a high standard of member satisfaction.
Processed wire transfers and account maintenance requests while adhering to financial regulations and internal security protocols.
Identified opportunities through transaction analysis, successfully cross-selling credit union products to boost revenue and engagement.
Guided members through complex banking procedures, resolving escalations with professionalism and clarity.
Improved operational efficiency by streamlining service workflows, contributing to faster response times and increased client satisfaction.
WALGREENS
Vallejo, CA
Shift Lead 10/2018 to 03/2019
Directed daily store operations and supervised staff to maximize productivity, ensure regulatory compliance, and enhance overall performance.
Resolved escalated customer concerns efficiently, driving increased satisfaction and repeat business in a fast- paced retail environment.
Maintained inventory accuracy and safety standards through systematic audits and proactive stock management.
Oversaw cash handling procedures, processed refunds, and ensured secure safe operations, contributing to consistent financial accuracy.
Built collaborative relationships with vendors, team members, and corporate partners to support seamless store functionality and strategic initiatives.
FANEUIL (COVERED CALIFORNIA)
Sacramento, California
Healthcare Customer Service 11/2017 to 03/2018
Assisted customers with selecting suitable healthcare plans, improving satisfaction through clear guidance and resolution of billing inquiries.
Clarified complex insurance terminology to support informed decision-making and boost customer confidence.
Verified Medi-Cal eligibility by conducting thorough residency and income reviews, ensuring regulatory compliance and process accuracy.
Escalated unresolved concerns efficiently, upholding service standards and reinforcing customer trust in state healthcare systems.
Managed multi-step verification workflows and maintained detailed documentation, resolving complex disputes and improving case turnaround time.
XEROX (COMPNOVA)
Sacramento, California
Medi-Cal Claims Specialist 10/2014 to 03/2015
Resolved complex Medi-Cal billing inquiries, increasing provider satisfaction and ensuring regulatory compliance.
Facilitated provider enrollment by streamlining application processes and minimizing submission errors.
Interpreted and communicated patient eligibility details, expediting claims and reducing processing delays.
Investigated and resolved EHR-related issues, improving billing accuracy and provider operational support.
Validated claims using ICD-9/10 codes and modifiers, ensuring documentation accuracy and timely provider reimbursements.
WALMART
Richmond, CA
Pharmacy Technician/Clerk 02/2014 to 05/2014
Accurately entered patient data and prescriptions, ensuring compliance with regulatory standards and reducing errors.
Managed medication inventory, optimizing stock levels and ensuring safe storage in adherence to guidelines.
Processed insurance claims and resolved billing discrepancies, improving payment efficiency and customer satisfaction.
Educated patients on medication usage, enhancing their understanding of generic and brand options for informed decisions.
Streamlined prescription processing through automated systems, improving workflow efficiency and inventory tracking.
EDUCATION
MEDICAL BILLING AND CODING 05/2025
AAPC Online Classes
Self-paced program (Certification Pending)
VOCATIONAL SCHOOL 06/2022
Silicon Valley College, Walnut Creek, California
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