member services csr resume example with 12+ years of experience

(555) 432-1000,
, , 100 Montgomery St. 10th Floor
Professional Summary

Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.

  • Guest services
  • Inventory control procedures
  • Merchandising expertise
  • Loss prevention
  • Cash register operations
  • Product promotions
Ultimate Medical Academy Tampa, FL Expected in Associate of Science : Medical Billing and Coding - GPA :
Work History
Aetna/CVS Health - Member Services CSR
City, STATE, 08/2021 - Current
  • Answers questions and resolves issues based on phone calls/letters from members, providers, and plan sponsors
  • Triages resulting rework to appropriate staff.
  • Documents and tracks contacts with members, providers and plan sponsors
  • The CSR guides the member through their members plan of benefits, Aetna policy and procedures as well as having knowledge of resources to comply with any regulatory guidelines.
  • Creates an emotional connection with our members by understanding and engaging the member to the fullest to champion for our members' best health
  • Taking accountability to fully understand the member s needs by building a trusting and caring relationship with the member.Anticipates customer needs
  • Provides the customer with related information to answer the unasked questions, e.g. additional plan details, benefit plan details, member self-service tools, etc.
  • Uses customer service threshold framework to make financial decisions to resolve member issues
  • Explains member's rights and responsibilities in accordance with contract.
  • Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) via target system
  • Educates providers on our self-service options; Assists providers with credentialing and re-credentialing issues
  • Responds to requests received from Aetna's Law Document Center regarding litigation; lawsuits
  • Handles extensive file review requests. Assists in preparation of complaint trend reports
  • Assists in compiling claim data for customer audits.
  • Determines medical necessity, applicable coverage provisions and verifies member plan eligibility relating to incoming correspondence and internal referrals
  • Handles incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management
  • Performs review of member claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductible
  • Performs financial data maintenance as necessary.
  • Uses applicable system tools and resources to produce quality letters and spreadsheets in response to inquiries received

Qualifications Requirements and Preferences:

  • Customer Service experiences in a transaction based environment such as a call center or retail location preferred
  • Ability to be empathetic and compassionate.
  • Experience in a production environment
  • High School or GED equivalent
Corvel Corporation - MEDICAL BILL REVIEW ANALYST (Remote)
City, STATE, 03/2019 - 04/2021
  • Applied knowledge of medical terminology, medical billing guidelines, and fee schedules, Including CPT/ICD/HCPS coding and Knowledge of UB-O4 and CMS- 1500 form types.
  • Researched CPT and ICD-10 coding discrepancies for compliance and reimbursement accuracy for over 150 bills per day.
  • Located errors and promptly refiled rejected claims.
  • Identified appropriateness of charges and associated coding on bills assigned daily.
  • Calculated and applied savings associated with reviews.
  • Communicate findings with stakeholders and supervision.
  • Comply with customer special handling and jurisdictional guidelines.
  • Utilize written and online resources support good decision making.
  • Utilize review system to appropriately document work and final conclusions.
City, STATE, 09/2009 - 03/2019
  • Obtained benefits and prior approval from patient’s insurance carrier for all surgical cases.
  • Documented benefits and prior approval including notes in PM Alert system.
  • Acted as effective liaison between patient, surgeon, primary care physician, insurance company, hospital, and patient surgery coordinator in disseminating insurance benefits.
  • Assessed situations and forwarded to physican's team or other staff as appropriate.
  • If needed, prepared and mailed PreCert information so that the patient will receive it in a timely manner.
  • Maintained accurate account of all surgical insurance verifications electronically.
  • Working knowledge of patient management systems including insurance, information, and verification modules.
  • Knowledge of Retina processes within precert dept to be able to obtain the most accurate authorization needed for the patient. ( buy and bill, specialty pharmacy, samples vs stock, Step Therapy, benefits investigations, and financial assistance).
  • Applied necessary communication in the PM and EHR alerts to the clinical teams.
  • Maintained knowledge of Cornea Cross Linking procedure to accurately obtain prior authorization, pre-determination. Communicates benefits and collection amounts with the patient prior to the surgery being scheduled. Completes HER telephone call log for accurate communication with the clinical teams.
  • Maintained and obtained necessary VA authorizations for all HEC services provided to veteran patients.
  • Obtained prior authorizations for necessarily ordered radiology (MRI’s, and CT Scans) for HEC providers.
  • Ensured patient confidentiality and adheres to HIPAA requirements using all methods necessary including non-disclosure to unauthorized personnel, limiting record access and shredding discarded patient information.

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Resume Overview

School Attended

  • Ultimate Medical Academy

Job Titles Held:

  • Member Services CSR


  • Associate of Science

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