Customer Service Health
Resume:
Pamela Oakes
Canton MI *****
OBJECTIVE: To obtain a challenging position were my skill could be fully utilized.
EDUCATION:
Highland Park Community College
COURSES: Accounting, Bookkeeping, Advanced typing, and other basic courses. Certificate received 9/88.
Fall 1996 Detroit College of Business
COURSES: Windows, WordPerfect 6.0, Microsoft Word 6.0, and Microsoft Excel.
COMPUTER
EXPERIENCE: WordPerfect 6.0, Microsoft Word 6.0, Microsoft Excel, and Health Match. HFH Programs: MAINFRAME, MPAC, AS4X, and MIMS.
Employment:
08/08-Present Coordinated Behavioral Health Mgmt. Health Alliance Plan/Henry Ford Health System Detroit, MI
Duties: Provides outreach, to members with behavioral health conditions. Responds to and coordinates services for emergent or urgent requests in a timely and professional manner. Perform clinical assessments and telephone triage as indicated. Effectively communicates with customers and providers establishing and maintaining positive relationships. Completes data entry and paperwork in a timely manner according to guidelines of the department and accrediting bodies. Maintains confidentiality according to Federal Rules and Regulations. Identifies and manages problem cases. Effectively communicates with individuals, departments and other entities for timely resolution of the identified problems. Cooperatively within a team structure.
01/06-07/08 Provider Appeals Coordinator Health Alliance Plan/Henry Ford Health
System Detroit, MI
Duties: responsible for the day to day functions of the tracking and trending of all appeals. The coordinator will act as the primary investigator and contact provider via phone or mail. Will appropriately acknowledge the receipt of all provider appeals. By gathering of all pertinent and relevant information from the provider regarding the appeals, determining the appropriate resolution of the provider appeal per standard policies and procedures; and notifying the appropriate parties of the resolution and ensuring that all internal processes are completed to resolve in a timely manner. Compose written correspondence to the provider in accordance to plan policy. Conduct non-biased, accurate, timely and comprehensive investigation of all the facts related to the provider appeal. Thoroughly document all action taken on behalf of the provider to resolve the appeal. Ensure that all appeals are processed in adherence to the Centers for Medicare guidelines and plan policy. Prepare case files for Medical Director Review of all provider appeals as appropriate. Prepare clear, objective, accurate and comprehensive case histories for presentation and consideration at committee meetings (including Board of Directors).Maintain accurate and timely documentation, including complete files of all provider appeals. Prepare monthly and quarterly reports as requested. Identify training opportunities and potential system and process improvements relating to provider appeal data. Participate in periodic review and update of all provider appeal policies and procedures to reflect appropriate legal and CCMS requirements as well as participate in periodic CCMS Audit preparations and regulator meetings. Maintain a positive and professional relationship with staff, providers, members, and regulators.
1/99 – 12/05
Senior Utilization Management Associate, Health Alliance Plan/Henry Ford
Health System Detroit, MI
Duties: Customer Service Representative and staff. Provide services/support for Admissions, Referrals and Pre-Certifications. Medical coding monitors the utilization of resources and proper administration for insurance policy. Answers a variety of patient and staff inquire by phone, in person, and in writing. Orients and educates HAP members regarding there insurance policy. Authorizes payment for services purchased for members receiving services outside of the Henry Ford system. Provides means for resolving patient’s complaints and handling other problems
REFERENCES PROVIDED UPON REQUEST
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