Objective

• To obtain a meaningful position with a successful company with an opportunity for career advancement.
• I want to use all my customer service, healthcare, and managerial experience in order to benefit the industry in which I work and help customers with their varied consumer experiences.

PROFESSIONAL EXPERIENCE

Confidential, Phoenix, AZ

Senior Customer Service Specialist

Responsibilities:

• Responsible for providing expertise and customer service support to members, customers, and/or providers through direct phone - based interaction in a call center setting.
• Coordinated, Supervised, and was Accountable for the daily/weekly/monthly activities of a team of 15 customer service members and the impact of my work was most often at the team level.
• Set priorities for the team to ensure task completion and performance goals are met, such as: Quality, Adherence, Service Level and AHT.
• Coordinated work activities with other supervisors, managers, departments, etc.
• Identified and resolved operational problems using defined processes, expertise, and sound judgment, while being responsible for resolving a wide variety of inquiries.
• Provided coaching and feedback to team members, including formal Corrective Action Plans.
• Conducted Annual Performance Reviews for team members.

Confidential, Phoenix, AZ

Team Lead to Customer Service Team

Responsibilities:

• Responsible for providing expertise and customer service support to members, customers, and/or providers through direct phone-based interaction in a call center setting.
• Coordinated, Supervised, and was Accountable for the daily/weekly/monthly activities of a team of 15 customer service members and the impact of my work was most often at the team level.
• Set priorities for the team to ensure task completion and performance goals are met, such as: Quality, Adherence, Service Level and AHT.
• Coordinated work activities with other supervisors, managers, departments, etc.
• Identified and resolved operational problems using defined processes, expertise, and sound judgment, while being responsible for resolving a wide variety of inquiries.
• Provided coaching and feedback to team members, including formal Corrective Action Plans.
• Conducted Annual Performance Reviews for team members.

Confidential, Phoenix, AZ

Customer Service Representative

Responsibilities:

• Ensured accurate data entry into medical management system by key-entering authorizations and referrals requests and supported Hub Clinical Operations by prioritizing faxed documents, forwarding faxes to appropriate parties for handling, and processing requests.
• Assisted beneficiaries with locating local network providers.
• Processed authorization and referral requests and key-entered data from faxed documents in the on-line medical management system.
• Read TIFF (Tagged Image File Format) communications detailing diagnosis and requested services and procedures.
• Determined beneficiary eligibility for health services by accessing TriWest West Region Desktop Application.
• Reviewed each Military Treatment Facility Capability Report and initiates the Right of First Refusal process for the beneficiary, faxes required paperwork to the facility, and key-enters response (whether care will be provided by the Military Treatment Facility or referred to a network provider).
• Referred beneficiaries to network providers by reviewing TRINET Provider Directory and selecting providers by specialty and location.
• Communicated with other departments, medical providers, and beneficiaries to clarify documentation prior to processing.
• Audited peer authorizations for accuracy and completeness.in addition to performing other duties as assigned.
• Worked within a standard call center office environment, Department of Defense security clearance was required.

Confidential, Phoenix, AZ

Customer Service Representative

Responsibilities:

• Functioned as primary customer contact by receiving calls, letters or other communication from customers, both internal and external, concerning information related to a specific program.
• Investigated problems using computer systems, databases, and established procedures, and then contacted customers with solutions.
• Obtained further information or routes call to appropriate party. Works within established department guidelines.
• Ability to establish and maintain positive customer relations with patients, advocates and pharmacists.
• Active listening skills and ability to proactively solve problems using established program procedures and business rules.
• Strong oral and written communication skills and ability to effectively communicate program procedural information to patients, advocates and pharmacists.
• Multi-tasking abilities (must be able to enter data into computer system while maintaining conversation with callers; talk and type).
• Ability to quickly learn and retain new program information and apply knowledge to enhance quality of call responses.
• Ability to positively receive and apply constructive feedback on performance issues and call monitor activities.
• Position required a high level of knowledge of active listening skills.

Confidential, Phoenix, AZ

Prior Auth Representative / Inbound Queue Representative

Responsibilities:

• Supported comprehensive coordination of medical services including intake, screening and referrals to Confidential Medical Service Programs, prior authorizations, and customer service.
• Promoted quality effectiveness of Healthcare Services.
• I facilitated the processing of written and telephone requested services by providers for Confidential members within established AHCCCS timeframes and followed MCP guidelines for medical necessity.
• I forwarded appropriate prior authorization requests to the Medical Director for review with pertinent clinical information, when applicable.
• I maintained data entry and provider notification to decrease delays in service to members and answered a high volume of calls within AHCCCS mandated timeframes.
• I was responsible for maintaining all Quality and Call Center Statistical standards on a daily basis and I consistently exceeded these expectations.

Confidential, Phoenix, AZ

Prior Authorizations Representative / Team Lead

Responsibilities:

• Served as team Leader for CMS staff; monitored Physical Medicine case flow for accuracy and timeliness; researched pending cases without activity for 2 days; answered routine questions. Trained new and existing employees and Identified training issues for Physical Medicine staff and notified manager while maintaining compliance with interdepartmental procedures, policies and Confidential operational principles. Familiar with client profiles and requirements also. Utilized available licensed health professionals to ensure quality performance of duties and Quality Assurance in all programs. Complete special projects as assigned by the manager.
• Apply knowledge of and adhere to the National UM/WCUM Standards.
• Processed appeal requests according to appeal policy. Identified potential or existing system and/or procedural challenges, and notify manager and assist in resolution if needed.

Confidential, Phoenix, AZ

Team Lead

Responsibilities:

• Besides dispatching ambulances nationwide, I oversaw all functions of CSR’s, established and maintained good working relationships with providers, clients, co-workers, and regional office personnel.
• Complied with Logisticare rules and procedures while completing agent reports and reported stats to Call Center management.
• Assisted Call Center management in performing 90 day and annual evaluations of CSR’s, coordinated work schedules, vacation and leave requests of CSR’s, and maintained daily and weekly reports to Call Center management of all staff, provider and facility issues.
• Provided superior customer service to clients, efficient and accurate entering of all customer service requests into the data management system, and performed all gate keeping functions related to trip authorization, documenting and resolving complaints and issues.
• Monitored call stats, CSR aux work and call waiting times and maintain accurate call stat reporting to Call Center management weekly as well as performed other duties, as assigned.

Confidential, Phoenix, AZ

Prior Authorization Tech

Responsibilities:

• Facilitated the processing of written and telephone requested services by providers for Health Choice members within established timeframes and followed HCA guidelines for medical necessity.
• Maintained data entry and provider notification to decrease delays in service to members and I answered a high volume of calls within AHCCCS mandated timeframes.

Confidential, Phoenix, AZ

Rx Enrollment Specialist / CSR Team Lead

Responsibilities:

• As a Team Lead, I monitored CSR productivity and performance, oversaw call volume to ensure service standards are met, recommended operational improvements, promoted a working team environment by ensuring best practices are followed, I communicated expectations, achievements and processes through coaching, I evaluated performance, provided feedback, and worked to develop employee skills through ongoing coaching sessions. I monitored workflow by monitoring the queue, I provided real-time floor support interacting with CSR’s, I tracked and reported progress to management, served as a point of escalation for calls requiring a higher degree of expertise, and I took overflow calls as needed. I also trained new employees, identified workflow gaps and improvement opportunities, and managed incentive programs and special projects, as needed.
• As an Rx Enrollment Specialist, I connected with customers, in a call center setting, in order to educate them on Confidential benefits, such as Rightsource, and enroll them. I used customer service, sales, and product expertise to influence internal and external customers, optimizing business outcomes in the process. I built trust and rapport with customers by honoring my word. I championed the customer by keeping closely attuned to the needs and perspectives of Confidential customers in order to provide exceptional customer service. I also use this insight for the benefit of the business since the level of quality customer service does directly impact the company’s financial bottom line and the company’s overall success. I have a drive for excellence: I’m a fast and continuous learner who encourages others to learn as well. By constantly upgrading your own work, you achieve desired results and continue to grow and become a greater asset to the company, all while providing exceptional service.

Confidential, Phoenix, AZ

Intake Coordinator/Prior Auth/Home Health Coordinator/Customer Service Rep. /Team Lead

Responsibilities:

• In a call center setting, I gathered complex patient intake information from hospital discharge planners and case managers for recently discharged patients and obtained prior authorizations from several insurance companies. I then arranged for contracted home healthcare agencies to provide the required care for these patients, for contracted rates, such as Nursing, Physical Therapy, Occupational Therapy, Speech Therapy, Home Infusion Therapy, Acute and Chronic Infusion, Home Respiratory Services, Durable Medical Equipment, Orthotics and Prosthetics, etc.
• I was promoted to Team Lead and I managed a group of 15-20 on an on-going basis for my supervisor. I was responsible for Hiring, Training, Floor Support, and Terminations as well as daily call reports and CSR progress reports and coaching.

Confidential, Phoenix, AZ

Insurance Customer Service Representative / Team Lead

Responsibilities:

• We were a community-rated, government-ran health Insurance plan that provided healthcare coverage for almost 30,000 members and was designed to insure Arizona’s uninsured small business community.
• Answered inbound calls from/made outbound calls to insureds, providers, and other insurance agencies in order to provide quality customer service to members regarding their Medical, Dental, and/or Vision policies. I provided all pertinent information to Mercy Healthcare, University Physicians, Care1st Arizona, and Arizona Foundation for Medical Care’s prior auth departments so prior authorizations could be issued.
• Consistently handled questions regarding prior authorizations, prior insurance information and creditable coverage, past medical history, demographics, pre-existing condition information, medications, eligibility and benefits information, etc.
• Processed requests regarding claims, premiums, changes, renewals, add-ons, terminations, reinstatements, exceptions, new group enrollments, and any other customer related concerns such as several rate increases and processed payments.