Customer Service Patient Access
Resume:
KALANDRIA PHILLIPS
Thomasville, GA *****
*******************@*****.***
Professional Summary
Detail-oriented Patient Access Representative with extensive medical services background and strong work ethic. Managed patient-related accounts receivables at large medical facility and achieved 90% repayment rate. Excellent communications skills and empathetic nature enabled achievement of positive outcomes. Enhanced customer loyalty through effective resolution strategies and proactive outreach initiatives. Recognized for exceptional communication skills and ability to analyze data for process improvements, driving significant increases in client retention and satisfaction. Work Experience
Customer Service Specialist
Concentrix-Remote
August 2023 to Present
Develop and maintain working knowledge of current products and services offered by the company Answer all calls and emails in a timely manner, in adherence to their goals Document all call information according to standard operating procedures Answer questions about products and services, retail stores, general service line information and other information as necessary based on customer call needs Process orders, route calls to appropriate resource, and follow up on customer calls where necessary Review all required documentation to ensure accuracy Accurately process, verify, and/or submit documentation and orders Complete insurance verification to determine patient’s eligibility, coverage, co-insurances, and deductibles
Obtain pre-authorization if required by an insurance carrier and process physician orders to insurance carriers for approval and authorization when required Must be able to navigate through multiple online EMR systems to obtain applicable documentation Enter and review all pertinent information in EMR system including authorizations and expiration dates Communicate with Customer Service and Management on an on-going basis regarding any noticed trends with insurance companies
Verify insurance carriers are listed in the company’s database system, if not request the new carrier is entered
Responsible for contacting patient when documentation received does not meet payer guidelines to provide updates and offer additional options to facilitate the referral process. Meet quality assurance requirements and other key performance metrics Facilitate resolution on customer complaints and problem solving Pays attention to detail and has great organizational skills Actively listens to patients and handle stressful situations with compassion and empathy Flexible with the actual work and the hours of operation Utilize company provided tools to maintain quality. Some tools may include but are not limited to Authorization Guidelines, Insurance Guidelines, Fee Schedules, NPI (National Provider Identifier), PECOS
(the Medicare Provider Enrollment, Chain, and Ownership System) and “How-To” documents Prior Authorization Specialist
Everise-Remote
June 2022 to April 2023
Complete prescription intake process including verification of insurance coverage Assist physician’s offices through the prior authorization and appeals process Research financial assistance options for patients through copay cards, foundations, and assistance programs
Coordinate prescription processing and delivery with dispensing pharmacies Manage and triage high volume of customer service phone calls while managing day to day operations Build relationships with physicians, manufacturer sales representatives, pharmacies, patients, and other team members to optimize workflow and achieve program goals Ensure proper documentation of process flow from prescription initiation through completion Provide timely updates to physicians, pharmacies, and manufacturers regarding prescription status Interface with IT department to improve system functionality and workflow Attend team meetings to support ongoing program development Other responsibilities as assigned
Success in this position is defined by high levels of customer service and timely processing of prescriptions through all phases
Compliance with the provisions of the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations, as amended (“HIPAA”)
Grievance and Appeals Analyst
Foundever-Remote
February 2020 to December 2021
Research incoming electronic appeals, complaints and grievance to identify if appropriate for unit based upon published business responsibilities. Identify correct resource and reroute inappropriate work items that do not meet appeals, complaints and grievance criteria. Research Standard Plan Design or Certification of Coverage relevant to the member to determine accuracy/appropriateness of benefit/administrative denial. Research claim processing logic to verify accuracy of claim payment, member eligibility data, billing/ payment status, prior to initiation of appeal process. Identify and research all components within member or provider/practitioner appeals, complaints and grievance for all products and services.
Triage incomplete components of appeals, complaints and grievance to appropriate subject matter expert within another business unit(s) for resolution response content to be included in final resolution response.
Responsible for coordination of all components of appeals, complaints and grievance including final communication to member/provider for final resolution and closure. Serve as a technical resource to colleagues regarding appeals, complaints and grievance issues, and similar situations requiring a higher level of expertise. Identifies trends and emerging issues and reports on and gives input on potential solutions. Ability to meet demands of a high paced environment with tight turnaround times. Ability to make appropriate decisions based upon Aetna's current policies/guidelines. Collaborative working relationships.
Thorough knowledge of member and/or provider appeals, complaints and grievance policies. Strong analytical skills focusing on accuracy and attention to detail. Knowledge of clinical terminology, regulatory and accreditation requirements. Excellent verbal and written communication skills. Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word
Chronic Care Manager/ Medical Assistant
Nsight Health-Remote
December 2016 to March 2019
· Managed complex caseloads, ensuring timely assessment, intervention, and documentation for optimal care outcomes.
· Promoted patient self-management by providing education on chronic condition management and healthy lifestyle choices.
· Arranged transportation and documented details of discharge transition plans.
· Communicated with healthcare providers to facilitate continuity of care.
· Maintained detailed records in compliance with agency standards and regulations.
· Coordinated referrals to specialists, hospitalizations, ER visits, ancillary testing, and other enabling services for patients.
· Participated in team meetings and trainings to stay updated on best practices and new developments in care management.
· Served as a liaison between patients, families, physicians, insurance providers, and other healthcare professionals for seamless care coordination efforts.
· Maintained strict adherence to professional ethics and confidentiality guidelines, safeguarding sensitive information and promoting trust.
Inside Sales Representative
Vector Marketing Company-Tallahassee, FL
November 2014 to January 2018
· Increased sales revenue by building strong relationships with clients and providing insightful product recommendations.
· Enhanced customer satisfaction through attentive service, addressing concerns promptly, and offering tailored solutions.
· Maintained up-to-date knowledge of available products to best serve customers and maximize sales potential.
· Met or exceeded sales targets and quotas to contribute to overall sales goals and revenue of company.
· Used CRM software to maintain detailed contact logs and account records.
· Exceeded monthly quotas consistently by employing persuasive sales techniques and leveraging in- depth product knowledge.
· Nurtured long-term customer relationships through regular check-ins, keeping them informed of relevant updates and promotions.
· Attended meeting and sales events to learn latest developments and brainstorm new sales strategies.
· Participated in industry events and trade shows to network with prospects, gather leads, and increase brand awareness.
Customer Service Representative
F.H. Cann & Assoc.-Remote
February 2012 to October 2015
· Managed high-stress situations effectively, maintaining professionalism under pressure while resolving disputes or conflicts.
· Resolved customer complaints with empathy, resulting in increased loyalty and repeat business.
· Developed strong product knowledge to provide informed recommendations based on individual customer needs.
· Developed rapport with customers through active listening skills, leading to higher retention rates and positive feedback from clients.
· Maintained detailed records of customer interactions, ensuring proper follow-up and resolution of issues.
· Collaborated with team members to develop best practices for consistent customer service delivery.
· Contributed to sales growth by upselling products and services based on individual customer requirements.
· Provided coaching and mentoring to new hires, contributing to their successful integration into the team.
· Exceeded performance metrics consistently, earning recognition as a top performer within the team. Education
Associate of Science in Healthcare Administration
Ultimate Medical Academy
October 2018 to October 2018
Bachelor of Science in Health Sciences
Southern New Hampshire University-Hooksett, NH
Skills
• Medical terminology
• Claims processing
• Complaint handling
• Policy adherence
• Assertiveness
• EHR management
• Insurance verification
• Appointment scheduling
• CRM software
• HIPAA compliance
• Call center experience
• Insurance billing
• Insurance claims follow-up
• Data entry proficiency
• Customer relations
• Medical billing
• EMR
Certifications and Licenses
Certified Medical Assistant
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