Healthcare Benefits & Claims Specialist

RICCIA THOMAS

Lakewood, WA *****

******.********@******.*** 843-***-****

PROFESSIONAL SUMMARY

Experienced healthcare service professional with 10+ years in explanation of health benefits, prior authorizations and customer support. Proven ability to resolve complex claims issues, ensure HIPAA compliance, and guide patients through insurance systems. Strong background in Medicaid/Medicare, claims research, and member education. Poised to contribute efficient customer service with precision and integrity.

PROFESSIONAL EXPERIENCE

Public Benefits Specialist 1

Washington State Department of Social and Health Services – Lakewood, WA

January 2025 – Present

•Determine eligibility for Medicaid, SNAP, and financial assistance programs under federal and state regulations

•Process new applications, status changes, and re-certifications with strict attention to compliance

•Educate clients on benefit rights, responsibilities, and available healthcare resources

•Respond to inquiries with empathy and accuracy in a high-volume environment

Remote Service Advocate

Optum Care Network – Tacoma, WA February 2020 – April 2024

•Handled complex health insurance inquiries including claims status, benefits verification, and retroactive certification

•Researched and resolved escalated cases involving Medicare/Medicaid claims and provider coordination

•Supported compliance by documenting interactions and resolutions using CRM software

•Mentored new staff in call handling, knowledge base navigation, and member advocacy

•Promoted use of digital platforms such as myuhc.com and Lifeprint Health

Intake Coordinator / Care Navigator

Northwest Integrated Health – Tacoma, WA

July 2019 – January 2020

•Verified patient insurance benefits and coordinated referrals, authorizations, and transportation

•Scheduled intake assessments and ensured medical documentation was complete and compliant

•Matched patients with appropriate providers based on clinical and insurance factors

Provider / Customer Service Specialist

Coordinated Care – Tacoma, WA

November 2015 – January 2019

•Resolved provider and member inquiries related to claims processing, eligibility, and prior authorizations

•Identified billing and payment discrepancies; escalated cases for reprocessing when appropriate

•Educated stakeholders on health plan policies and portals for self-service

•Worked closely with internal departments to improve service processes and turnaround times

EDUCATION

Certificate – Office Administration (or relevant area)

Bates Technical College – Tacoma, WA

January 2006 – January 2007

High School Diploma

Stadium High School – Tacoma, WA

January 2002 – July 2005

RELEVANT SKILLS

•Claims Research & Resolution (Medicaid, Medicare, Commercial)

•Eligibility Determination & Public Benefits Administration

•HIPAA Compliance & Confidentiality

•CRM & OMNI Systems

•Salesforce

•HEDIS

•Authorization & Referrals

•Appeals & Grievances process

•DME (durable medical equipment)

•Medical Billing Support

•Technical Support & Member Education

•CITRIX

•EnterpriseNow

•PeopleNet

•Amysis

•Macess

•NICE

•Facets

•SharePoint

•TrueCare

•Workday

•Avaya, VoIP, Active Directory

•Quality Assurance & Documentation

•Microsoft Word, Office

•Genesys

•ProviderOne

•Epic

•Microsoft Teams

•Video Conferencing

•CVS Caremark

•Availity

•OMNI

Contact this candidate