Customer Service Claim Representative

*** ****** **, *******, **, ***** •

*****************.**@*****.*** • 478-***-****

DEMETRIA MITCHELL

Claim Representative

PROFESSIONAL SUMMARY

Claim Representative with over 5 years of experience in customer satisfaction and healthcare service optimization. Skilled in CPT and ICD codes, quality management, and staff training, enhancing client support and communication. Committed to advancing healthcare management processes, ensuring clients receive exceptional service and fostering a future of innovative care solutions. EMPLOYMENT HISTORY

PCA Dec 2024 - Present

Designated Cigna House Account

PCA ESI SUPPORT TEAM Apr 2024 - Jun 2024

ESI-PBM

Handled inbound calls of approximately 60-100 per day CUSTOMER SERVICE ADVOCATE ONERX/PBM CIGNA HOUSE ACCT Aug 2023 - Present Cigna Pharmacy

Provide high-level customer service to clients and prospects

• Handle Pre-Enrollment questions and concerns

• Respond to inquiries and resolve customer complaints

• Handle 20-50 calls per day

• Assist members with understanding of claims, deductibles and out of pocket expenses, prior authorization decisions

• Handle claim information and questions

MEDICAL ADMINISTRATIVE REPRESENTATIVE-REMOTE Feb 2023 - Apr 2023 Cigna-Pro Unlimited (Contract)

Medical record management and data entry

• Managed large amounts of data electronically, file documents in electronic filing software, faxing, scanning, and abstracting documents from electronic storage devices

• Utilized Quality Reporter (Cotiviti) to ensure the correct patient is being attached with record CLINICAL MANAGER/CLINICAL CARE COORDINATOR Nov 2020 - Jun 2022 Taylor Regional Hospital Hawkinsville, GA

Worked in collaboration with UHC and Peach State Health Plan that monitored and documented members’ outcomes by reviewing suspect care groups, medication adherence and assisting in closing gaps for their overall well-being

• Participated in CAHPS/HOS Action Plans; MAPCPI/MCAIP/ACV incentive programs for the hospital

• Received monthly PCOR to gauge in increasing each UHC patient outcome

• Interacted with patients to ensure they are receiving optimum care and adherence to their plan

• Ensured preventative health screenings were completed and HEDIS gaps in care were identified in a timely manner

• Managed administrative and clinical staff of daily management in providers’ offices for effective care

• Provided clinical and administrative support and oversaw hiring and training of staff Resolve technical issues on eCSR portal, enhancing user satisfaction and efficiency. Guide members through OmadaHealth enrollment, boosting engagement and program success. Manage inbound Cigna House Account calls, ensuring seamless support and client satisfaction. Facilitated seamless communication between members and support teams, enhancing user experience and fostering trust in services.

Coordinated with cross-functional teams to streamline support processes, achieving noticeable gains in call handling efficiency.

CERTIFIED MEDICAL ASSISTANT Sep 2020 - Nov 2020

Triaged patients and assisted in medical procedures with clinicians

• Handled referrals and prior authorizations of medical and procedures

• Scheduled outpatient diagnostic services or visits

• Abstraction of charts from one EMR to another and trained staff and clinicians

• Conducted COVID-19 testing and properly shipped to designated laboratory EDUCATION

MEDICAL BILLING AND CODING 2025

Penn Foster

Medical Billing and Coding

Certified Billing and Coding Specialist

MBA - HEALTHCARE MANAGEMENT May 2014

American InterContinental University

BBA - HEALTHCARE MANAGEMENT Oct 2013

American InterContinental University

ASSOCIATE OF ARTS - MEDICAL BILLING AND CODING Jan 2012 American InterContinental University

DIPLOMA - MEDICAL ASSISTING Sep 2005

Central Georgia Technical College Macon, GA

COURSES

NATIONAL CERTIFIED MEDICAL ASSISTANT 2005 - 2026

NCCT

SKILLS

Quality Management (Skillful), Prior Authorizations (Experienced), Medical Records (Expert), Medical Terminology (Experienced), ICD Codes (Experienced), CPT Codes (Experienced), Customer Service (Experienced), Data Entry, Healthcare Management (Experienced), Staff Training (Skillful), Clinical Support (Experienced).

REFERENCES

Erica Rodriguez, Cigna (*****.*********@***************.***, 304-***-****); June Chandler, Former coworker (****.********@*******.***, 229-***-****); Vivian Clemons, Former coworker (*********@******.***, 229-***-****).

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