Enrollment Systems Specialist - Healthcare Claims

Johnetta Rumper

Enrollment Systems Specialist

Killeen, 76542

Summary

Dedicated professional with four years of experience in healthcare administration and claims processing, seeking to leverage strong analytical and system utilization skills as an Enrollment Systems Specialist at Texas A&M University. Proven ability to manage data, document processes, and provide user support, directly aligning with the requirements for enhancing enrollment technologies and student success initiatives. Eager to contribute to operational effectiveness and student engagement through meticulous attention to detail and a commitment to continuous improvement.

Work Experience

Provider Relations and Prior Authorizations Specialist, United Health Group/ Optum, Remote 11/2024 – 04/2025

Addressed inbound calls and messages, utilizing scripts to effectively resolve customer inquiries and service issues.

Advocated for members and providers by managing inbound claim calls and addressing their support needs.

Maintained meticulous records of customer interactions and escalated complex issues as required.

Ensured the accuracy of records and diligently followed up on unresolved cases to achieve resolution.

Consistently met daily call volume and quality assurance targets while adhering to strict schedules.

Verified patient eligibility and assessed drug coverage details. Submitted prior authorization requests for medical services and prescriptions. Facilitated communication between healthcare providers, pharmacies, and patients to coordinate care.

Documented all communication logs and actions taken pertaining to member and provider interactions.

Monitored and followed up on pending or denied requests to ensure timely processing. Stayed current with evolving insurance policies, industry trends, and regulatory requirements.

Claim Examiner, Baylor Scott and White, Temple

02/2022 – 02/2024

Processed, researched, and adjudicated claims, ensuring accurate application of benefits for routine, uncomplicated medical claims (CMS 1500 and UB04) and Rx claims according to established guidelines.

Placed claims on hold as per departmental policies and procedures, followed up for resolution, and processed these claims promptly upon benefit/payment determination. Managed assigned claim inventory queues to ensure timely processing within established turnaround times.

Received, reviewed, and responded to account-related correspondence, taking necessary actions to resolve issues.

Maintained strict confidentiality in accordance with HIPAA guidelines. Reviewed output reports to confirm accurate benefit and rider determinations, ensuring the prompt payment of claims.

Coordinated the scanning of claims-related documents into member MACESS folders. Contributed to achieving departmental and organizational objectives through efficient claims processing.

Adhered to all company policies and procedures, including punctuality for work, lunch, and break periods.

Medical Claims Clerk, Department of Veteran Affairs, Austin 01/2019 – 09/2021

Processed, updated, purged, and suspended medical claims efficiently. Supported document monitoring activities to ensure adherence to VA policies and procedures.

Researched health records to resolve discrepancies and address claim-related problems. Reviewed all pertinent health documentation for veterans and active military families. Maintained daily production logs for medical claims processed, updated, purged, and suspended.

Managed accessible records and facilitated efficient care by handling health records in a timely and accurate manner.

General Clerk III, Combined Technical Service, LLC, Fort Hood 07/2018 – 10/2018

Provided essential support services to the US Army Operational Test Command. Collected and processed critical operational data. Collaborated closely with service members to facilitate daily surveys. Contributed to customer service initiatives and team-building exercises. Managed the daily collection of important information. Maintained daily accountability records.

Customer Service Representative, MACY’S, Dallas

08/2017 – 03/2018

Assisted customers with their daily shopping needs, providing a positive retail experience. Processed various payment methods, including cash and checks, and opened new customer accounts.

Maintained cleanliness and organization of the fitting rooms. Restocked merchandise and applied price tickets to items. Located and fulfilled merchandise orders via phone or online, preparing them for shipping to customers or other Macy's stores.

Achieved weekly and daily targets for new credit card applications. Systems Navigator - Exceptional Family Member Program, Armed Forces Services Corporation, Arlington

11/2014 – 11/2016

Facilitated family navigation through available systems of care, identifying Exceptional Family Member (EFM) and family member strengths and weaknesses. Assisted families relocating to new duty stations by providing essential information on local areas, physicians, and military resources.

Supported service members in developing Family Care Plans for deployment or field duty. Prepared comprehensive 'survival packets' for family members, including local school and transportation information, grocery details, activities, and area maps. Identified relevant support groups and social activities for EFM and family members, assisting with medical appointment scheduling and locating public transportation for appointments during service member deployment or field duty. Systems Navigator - Exceptional Family Member Program, Strategic Resources INC., Mclean 10/2012 – 11/2014

Guided families with special needs through available systems of care, pinpointing strengths and weaknesses of EFM and family members.

Provided new area information, physician referrals, and military-specific details to families transitioning to new duty stations.

Facilitated the development of Family Care Plans for service members during deployment or field operations.

Compiled essential 'survival packets' for family members, detailing area schools, transportation, grocery options, activities, and maps. Connected EFM and family members with support groups and social activities, and assisted in scheduling medical appointments and identifying public transportation routes. Certified Level III Paraprofessional, Killeen Independent School District, Killeen 08/1990 – 10/2012

Supported students in one-on-one or group learning environments within the Content Mastery Lab.

Delivered exceptional customer service, ensuring students understood all rules and regulations.

Provided academic assistance within the At-Risk Program, TAKS, TEKS, and STARR initiatives for students with low test scores through before and after-school programs, developing engaging activities to enhance testing skills. Supervised students in In-School Suspension, documenting behavioral incidents and reporting them to administration with detailed written reports. Inputted student data, including daily assignments, attendance, and time logs, into the C- LAB system.

Collected and distributed assignments, tests, and projects to teachers for students attending In-School Suspension.

Education

Bachelor of Science, Health Administration, Trident International University, Cypress Graduated Cum Laude.

Bachelor of Science, Business Administration, Trident International University, Cypress Master’s, Health Education, Trident International University, Cypress

Contact this candidate