Member Advocate Resume Example

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Jessica Claire
  • Montgomery Street, San Francisco, CA 94105
  • Home: (555) 432-1000
  • Cell:
Professional Summary
Highly motivated Sales Associate with extensive customer service and sales experience. Outgoing sales professional with track record of driving increased sales, improving buying experience and elevating company profile with target market.
Education and Training
Bachelor of Business Administration: , Expected in 2009
University of the Incarnate Word - San Antonio, TX
Master of Business Administration: , Expected in 2011
University of the Incarnate Word - San Antonio, TX
Skill Highlights
  • Guest services
  • Inventory control procedures
  • Merchandising expertise
  • Loss prevention
  • Cash register operations
  • Product promotions
Professional Experience
Member Advocate, 01/2012 to Current
Cvs HealthAmherst, NY,
  • Represent DentaQuest at community events and meetings to provide information to low-income populations about the dental benefits available to Medicaid and CHIP eligible members.
  • Establish, develop, and maintain partnerships with community organizations to identify and coordinate outreach opportunities that will facilitate growth in enrollment.
  • Conduct presentations to promote preventative dental care through good oral hygiene practices and compliance with Texas Health Steps checkups.
  • Provide case management to members in need of care coordination and assist members with claims issues and appeals.
Provider Relations Specialist, 01/2012 to
Amita HealthWauwatosa, WI,
  • Served as a liaison between the Medicaid and CHIP Managed Care contractor and health care providers.
  • Responsible for establishing and maintaining working relationships with the existing provider network.
  • Researched and resolved provider inquiries to include credentialing, claims issues, complaints and grievances.
  • Educated providers on new protocols, policies, and procedures to facilitate process improvements.
  • Ensured provider database and documentation was up to date, accurate, and complete.
  • Assisted with the development and implementation of provider training programs.
Business Development/Admissions Coordinator, 01/2011 to
AheadDetroit, MI,
  • Responsible for the development of admission statistics in a long-term acute care hospital setting by developing referral sources and converting referrals into admissions.
  • Responded to inquiries from hospital discharge planners, families, and other referral sources.
  • Conducted facility tours and informed families of potential patients of admission criteria, insurance coverage, and other costs associated with patient care.
  • Verified insurance benefits, obtained prior authorizations, and ensured that all potential barriers to claims payment were addressed and resolved prior to admission.
  • Coordinated the admissions process from start to end and alerted department heads of projected admissions, bed changes, discharges, and protocols for compliance with the patient's managed care insurance requirements.
Beneficiary Services Representative, 01/2004 to 01/2009
Regent Care CentersHumble, TX,
  • Acted as a liaison between TRICARE beneficiaries and health care providers.
  • Provided customer service support to beneficiaries that visited the local TRICARE Service Center by responding to benefit inquiries, resolving claims issues, and assisting with appeals, complaints, and grievances.
  • Advised beneficiaries of health and dental plan options and processed enrollments, disenrollments, primary care provider assignments, and other plan changes.
  • Provided customer support to the local military treatment facility administrative and clinical staff and assisted case management team with referrals and prior authorizations.
  • Traveled within the state of Texas to conduct benefit and enrollment presentations to different military groups, such as active duty service members transitioning to retirement, new active duty service members and base transfers, and National Guard and Reserve members called to full-time active duty services.
  • Provided health care providers with assistance on claims issues, appeals, complaints and grievances.
Office Coordinator, 01/2002 to 01/2004
St. Joseph Regional Health CenterCity, STATE,
  • Served as administrative and clinical support in various office settings throughout hospital organization to include outpatient physical, occupational, and speech therapy, inpatient skilled nursing, and outpatient wound care services.
  • Acquired insurance authorizations for patient services.
  • Prepared all required claims documentation including referrals, treatment plans, and other required correspondence to reduce incidence of denials.
  • Assisted other areas of hospital by investigating and resolving claims discrepancies in order to collect on unpaid patient accounts.
  • Played key role in the opening of hospital's new wound care center by assisting director in all areas of development, including creating policies and procedures, creating forms for clinical and billing staff, and obtaining insurance credentialing for providers.
Business Office Manager, 01/1XXX to 01/2001
Sulik Healthcare ServicesCity, STATE,
  • Managed business office for skilled nursing, rehabilitation, and long-term care facility.
  • Billed Medicaid, Medicare, and private insurance companies for services rendered to patients.
  • Managed facility's accounts receivables and accounts payables.
  • Prepared administrative reports for directors, Chief Financial Officer, and Chief Executive Officer.
  • Responsible for interviewing, hiring, training, and termination of office personnel.
accounts payables, accounts receivables, administrative, benefits, billing, oral, customer service, customer support, database, documentation, Financial, forms, hiring, insurance, director, meetings, office, network, nursing, personnel, policies, presentations, protocols, speech, statistics, training programs

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Resume Strength

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Resume Overview

School Attended
  • University of the Incarnate Word
  • University of the Incarnate Word
Job Titles Held:
  • Member Advocate
  • Provider Relations Specialist
  • Business Development/Admissions Coordinator
  • Beneficiary Services Representative
  • Office Coordinator
  • Business Office Manager
  • Bachelor of Business Administration
  • Master of Business Administration