Quality Assurance Customer Service
Resume:
Ariel Wheeler
Hewitt, TX *****
**************@*****.***
Work Experience
Funding Specialist
National Seating & Mobility-Remote
May 2024 to Present
Manages transaction cycle time (TCT) from Ready to Process to Funding Approval, making certain that all necessary steps are taken in the appropriate order ensuring timeliness of process and quality of funding approval.
Ensure all client information (Minimum Documentation Requirement) is correct and is put into the work order.
Verifies client benefits and coverage and communicates benefit information to client. Gathers and reviews documentation for funding package, including but not limited to: proper prescriptions, Letters of Medical Necessity (LMN), RTS evaluation information, price lists, forms (AOB, ABN, rent or purchase letter).
Communicates regularly with Physicians, Therapists, RTSs, and Clients in an effort to secure documentation as required by payer.
Investigates and updates any payer requirements.
Maintains communication with client throughout the process when applicable, including notifying them of financial responsibility.
Follows up with payer sources in order to obtain timely authorization, by properly working the Funding Work Queue.
Requests and obtains proper approval for work order credit exceptions. Conducts pre-purchase quality assurance to ensure all approvals and requirements are met prior to purchase of equipment.
Conducts pre-delivery verification to ensure all approvals and requirements are met prior to delivery of equipment.
Posts deliveries daily upon verification of proper documentation. Enrollment Representative (Seasonal)
Humana-Remote
September 2023 to January 2024
· Take inbound calls and explain enrollment programs and eligibility requirements to clients.
· Follow up with clients as needed through outbound calling.
· Collect required documentation and ensure it is filled out properly.
· Screen filing applications and change forms as needed.
· Address any enrollment issues or setbacks.
· Perform accurate data entry using a database.
Customer Advocate 1
HCSC BCBSTX-Waco, TX
January 2023 to September 2023
• Read and interpret contract language, gather appropriate documents, i.e., claim copies, claim history data, cancelled checks, on-line status, Explanation of Benefits (EOBs), and utilize applicable terminal screens including on-line documentation, intranet, and internet navigation.
• Collaborate with providers, families, and patients by ensuring communication is open and information appropriately shared (in compliance with HIPAA) to ensure member’s and provider’s needs are met.
• Assist members in assessing tools and decision-making around complex health issues, e.g., coordinate effective medical management.
• Provide appropriate amount of information in a timely manner and confirm customer understands information.
• Provide information and assistance to members with filing and pursuing a grievance or appeal.
• Flexible in dealing with customer needs, including deviations of normal practices, procedures, or benefit structures.
Health Concierge
CVS Health-Remote
January 2022 to January 2023
• Answers questions and resolves issues as a “single-point-of-contact” based on phone calls from plan sponsors, members, and providers. Provides customized interaction based on customer preference and individualized needs, creating an emotional connection with our members by understanding and engaging the member to the fullest.
• Anticipates customer needs. Provides the customer with related information to answer the unasked questions, e.g., additional plan details, benefit plan details, member self-service tools, etc.
• Uses customer service threshold framework to make financial decisions to resolve member issues.
• Educates and assists customers on various elements of benefit plan information and available services created to enhance the overall customer service experience with the company (i.e., assistance with member self-service tools, Consultation Opportunities – Simple Steps, Cost of Care Tools, Natural Alternatives Program, etc.).
• Other activities may include providing claim status information, benefit coverage interpretations, and explaining plan eligibility.
• Processes claim referrals, new claim hand-offs, and escalate issues as appropriate through the system for grievances and appeals.
• Initiates out-reach/welcome calls to ensure constituents expectations are met or exceeded. Identifies trends and any emerging customer service issues and works to develop solutions to address potential problems and/or plan features of interest as an approach to improve understanding of benefit plans and increase post-enrollment member satisfaction.
Prior Authorization Techician
Prime Therapeutics-Remote
October 2021 to January 2022
· Discuss medications, insurance, and prior authorization documents with patients.
· Get prior authorization approval from insurance firms and nurse managers.
· Reviewing and approving physician inquiries for pre-authorization and medical necessity requests based on established pharmacy guidelines and contract criteria.
· Appealing insurance companies after prior authorization refusals
· Supporting Fraud and Abuse program system oversight by reviewing medication utilization records.
· Answering calls from members and patient representatives in support of member prior authorizations
· Assisting the pharmacist with prior authorization request. Medical Billing Specialist
Meduit-Waco, TX
August 2019 to March 2021
· Speak to patients and insurance companies in a professional regarding their outstanding balances.
· Gathers information from patients, clients/family members, client clinical areas, government agencies, employers, third party payors and/or medical payment programs, etc. both in-person and by telephone to register patients, gather or update information, obtain referrals and pre-authorizations, complete appropriate forms, conduct evaluations, determine benefits and eligibility (insurance, public programs, etc.), determine financial responsibility and/or to identify sources of payment for services
· Requests, inputs, verifies, and modifies patient’s demographic, primary care provider, and payor information.
· Provides excellent customer service and timely response to questions and issues related to benefits, billing, claims, payments, etc.
· Answers questions by phone and provides quotes for services identifies financial resources, etc. in accordance with the client policies and procedures.
· Utilizes various databases and specialized computer software for revenue cycle activities including eligibility verifications, pre-authorizations, medical necessity, review/updating of patient accounts, etc.
· Inputs, retrieves, and modifies information and data stored in computerized systems and programs; generates reports using computer software.
· Explains charges, answers questions, and communicates a variety of requirements, policies, and procedures regarding patient financial care services and resources to patients, staff, payors, and agencies.
· Works with Claims and Collections to assist patients and their families with billing and payment activities to increase cash flow.
Medical Claims Specialist
Department of Veterans Affairs-Waco, TX
November 2017 to March 2019
· A medical claims specialist collects and processes the necessary information to complete the medical insurance claims process.
· They assess covered medical insurance losses, ensuring that claims fall within the scope of the policy.
· The specialist resolves the claim by either approving or denying documentation based on policy guidelines.
· Protecting company operations by maintaining the confidentiality of sensitive information is critical.
· Negotiate claim settlements and make recommendations for legal action when settlements are deemed non-negotiable.
· They check the accuracy and completeness of claim forms. Education
Certification in Medical Assisting
Penn Foster College
August 2023 to Present
High School Diploma
Midway High School
August 2009 to June 2013
Skills
• Communication
• Medical Billing
• Insurance Verification
• HIPAA
• Medical Terminology
• ICD-10
• Electronic Medical Records
• Customer Service
• Call Center
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