Customer Service Professional with Insurance Focus
Resume:
Tamika Council
Buffalo, NY *****
***************@*****.***
Willing to relocate: Anywhere
Authorized to work in the US for any employer
Work Experience
AMR-Buffalo, NY
May 2024 to Present
Answer 9-1-1 emergency and Nonemergency requests from different sources, such as phone calls, text messages, social media, and alarm systems.
Determine the type of emergency and its location and decide the appropriate response based on agency procedures.
Relay information to the appropriate first-responder agency. Billing Specialist
StaffBuffalo, LLC-Buffalo, NY
August 2023 to November 2023
• Verification of patient's benefits and coverage, which includes:
• Initial verification of patient's insurance for services
• Monthly re-verification of patient's insurances to identify insurance changes.
• Completion of tasks and verification information in the client's EMR
• Authorization requests for patient's insurances that require pre-certification.
• Initial authorization request made to insurance companies.
• Submission of necessary medical documentation from the client's EMR to support the authorization request.
• Subsequent authorization requests to insurance companies
• Physician Orders Tracking management, which includes:
• Sending of initial unsigned physician orders to physician offices and contacts for signature
• Follow-up and strategy on any aged unsigned physician orders
• Checking in and compliance review of signed physician orders into the client's EMR systems
• Development and maintenance of internal spreadsheets and databases, as necessary
• Training staff, as needed.Work with Epic, Medent, Connect Medicare, Navinet, Epaces, Availity, HealtheLink, Intranet, Fidelis, and Citrix.
Insurance Specialist II (IS2)
Abbvie (Remote)-Mobile, AL
December 2022 to February 2023
• Provide subject matter expertise and best-in-class customer service for all inbound and outbound customer calls to drive first call resolution.
• Provide insurance coverage, verification details prior authorization statues and alternate funding options for existing and newly launched products.
• Provide offices with current plan forms, portals, and websites for prior authorizations and appeal submissions. Clearly communicate and educate customers on results of the investigation. ·
• Investigate and problem solve for patients experiencing escalated issues such as disadvantaged or complex access, savings card/copay card challenges or non-preferred formulary issues, and /or potentially contacting the filling pharmacy or Payor. ·
• Quickly learn and execute business process and system changes for all drugs and channel sources as applicable.·
• Accurately communicate insurance details to HCP and patients. ·Identify potential Adverse Event situations for reporting to Pharmacovigilance ensuring AbbVie meets FDA regulations. Prior Authorization Specialist
RxBenefits, Inc (Remote)-Birmingham, AL
July 2021 to June 2022
• Responsible for obtaining pre-certifications and pre-authorizations for procedures and medications, scheduling appointments for outpatient testing with other providers, transcribes and triages patient calls to physicians, coordinates patient appointments/orders.
• Review chart documentation to ensure patient meets medical policy guideline. Prioritize incoming authorization requests according to urgencies. Obtain authorization via payer website or by phone and follow up regularly on pending cases.
• Maintain individual payer files to include up to date requirements needed to successfully obtain authorization. Initiate appeals for denied authorizations. Respond to clinic questions regarding payer medical policy guidelines.
• Confirm accuracy of CPT and ICD-10 diagnoses in the procedure order. Contact patients to discuss authorization status. Other duties as assigned. Understanding of payer medical policy guidelines while utilizing these guidelines to manage authorizations effectively. Sales Associate
Bath & Body Works-Buffalo, NY
October 2019 to January 2020
• Supports delivering sales plan through selling effectiveness. Meet selling goals/expectations during scheduled shifts.
• Assist with floor sets, window changes, visual presentations, stocking, inventory, and signage placement.
• Operational Excellence. Abide by Loss Prevention and safety messages in daily operations Customer Service Representative
Meritain Health/Third party-Buffalo, NY
May 2016 to September 2019
Responsible for responding quickly and professionally to all members and providers inquiring about the member’s healthcare plan. Educate the member about their healthcare plan and coverage. (Medical, dental, vision, etc) As well as quoting benefits and providing claim status.Request review of claims by sending a claim to pricing on behalf of the member or provider. Documentation review if Applicable. Providing appeal status and pre-certification, Authorization procedure/status. Follow established service quality standards and meet established telephone order processing time standards (talk time, after call work, order accuracy, etc.)
Education
Computer Science (High school diploma)
Samuel W. Wolfson High School-Jacksonville, FL
September 1994 to June 1998
Skills
• Negotiation
• Medical Coding
• Time management
• Pharmacy technician experience
• Customer service
• ICD-9
• ICD-10
• CPT coding
• EMR Systems
• Documentation Review
• Citrix
• Insurance verification
• AWS
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