LiveCareer-Resume

pbm cdr quality ii resume example with 20+ years of experience

Jessica Claire
  • , , 609 Johnson Ave., 49204, Tulsa, OK 100 Montgomery St. 10th Floor
  • Home: (555) 432-1000
  • Cell:
  • resumesample@example.com
Summary

Strategic Quality Analyst versed in developing standard operating procedures and training materials to promote adherence to quality standards. Dedicated to identifying operational pain points and implementing actionable improvements reduce corporate costs and increase consistency of quality.

Skills
  • SKILLS & ABILITIES
  • Adapt quickly to service the constant challenges and changes in the health care industry
  • Self-motivated and detailed oriented with strong organizational skills
  • Strong analytical, written, and oral skills
  • Proficient in the use of Microsoft Excel, Word, PowerPoint, Outlook, and Microsoft Teams as well as Sales Force
  • Organizational Skills
  • Problem Resolution
  • Training & Development
  • Reliable & Trustworthy
  • Supervision & Leadership
Experience
PBM CDR Quality II, 03/2018 to Current
CVS HEALTHCity, STATE,
  • Prepare and complete internal government audits on pharmacy claims for Department of Defense, Medicaid, Medicare, Indian Health Services, and Veteran Affairs to ensure compliance with state laws, federal laws, and regulations
  • Additionally, I prepared and completed commercial pharmacy audits on paper claims for Direct Member Reimbursement in which I reviewed, analyzed, and reported results of the quality monitoring process, assisted in implementing process improvement, assisted in determining client and company compliance policies, quality guidelines, and regulatory requirements.
  • Identified quality trends to investigate system flaws, process inefficiencies and training needs.
  • Participated in calibration sessions with stakeholders to promote consistent alignment on policies and processes.
  • Maintained policy, procedures, work instructions and projects for quality and continuous improvement agendas.
  • Contributed to business growth by confirming customer satisfaction with service and quality.
PBM CLAIMS PROCESSOR III, 06/2012 to 03/2018
CVS HEALTHCity, STATE,
  • Evaluate and process pharmacy claims based on plan benefits, maintain monthly reports for expected company reporting, assist in creating and updating work instructions for current work processes to maintain efficiency, consistency, and quality in work procedures.
  • Identified client service improvement opportunities in collaboration with team leads and managers to resolve problems.
  • Processed claims for payment or forwarded to appropriate personnel for further investigation
  • Verified claim data correctness in preparation for processing.
  • Processed claims according to established quality and production standards and made corrections and adjustments to solve problems.
  • Checked documentation for appropriate coding, catching errors and making revisions.
  • Organized information by using spreadsheets, databases or word processing applications.
  • Planned and conducted investigations of claims to confirm coverage and compensability.
  • Researched and reviewed information to determine validity of insurance claims and contacted companies and customers about decisions.
  • Communicated with other departments to establish action plans and manage open claims to closure.
PBM CUSTOMER CARE REPRESENTATIVE, 10/2007 to 06/2012
CVS CAREMARKCity, STATE,
  • Efficiently processed claims for Medicaid/DOD/DVA/and Member reimbursement pharmacy claims while handling complex and escalated member benefit and pharmacy calls in a high-volume call center for members and providers
  • Maintain rapport with members for the purpose of improving superior customer service
  • Conduct detailed analysis on complaints and member issues to recognize trends for the purpose of documentation by management to improve customer satisfaction.
  • Maintained high satisfaction score by consistently resolving first-call issues.
  • Interacted with customers to provide and process information in response to inquiries, concerns and requests about services and products.
  • Researched resolutions, contacted necessary departments and responded to customer by phone, mail or fax as follow-up.
  • Surpassed quality target by working through scripted response plans and applying personal knowledge base to resolve concerns.
SR INVOICE & QUALITY CONTROL SPECIALIST, 12/2000 to 09/2006
CPS ENERGYCity, STATE,
  • Resolved escalated customer complaints, billing issues and inquiries while operating within corporate policy and guidelines
  • Through team effort established and implemented the Resolution Help Desk to resolve escalated issues and assisted as a Subject Matter Expert (SME) in implementing a new Computer System SAP.
  • Participated in calibration sessions with stakeholders to promote consistent alignment on policies and processes.
  • Contributed to business growth by confirming customer satisfaction with service and quality.
  • Maintained quality assurance procedure documentation.
  • Monitored completed work and provided feedback to improve team member performance.
  • Created, edited and updated project manuals and technical documentation used by entire QA team.
  • Maintained policy, procedures, work instructions and projects for quality and continuous improvement agendas.
  • Implemented quality control objectives to resolve production issues, optimize product reliability and reduce costs.
  • Identified quality trends to investigate system flaws, process inefficiencies and training needs.
Education and Training
Bachelor of Science: Health Care Administration, Expected in 01/2020 to Grand Canyon University - Phoenix, AZ
GPA:
BACHELOR OF SCIENCE: HEALTHCARE ADMINISTRATION, Expected in to GRAND CANYON UNIVERSITY - PHOENIX, AZ
GPA:

By clicking Customize This Resume, you agree to our Terms of Use and Privacy Policy

Your data is safe with us

Any information uploaded, such as a resume, or input by the user is owned solely by the user, not LiveCareer. For further information, please visit our Terms of Use.

Resume Overview

School Attended

  • Grand Canyon University
  • GRAND CANYON UNIVERSITY

Job Titles Held:

  • PBM CDR Quality II
  • PBM CLAIMS PROCESSOR III
  • PBM CUSTOMER CARE REPRESENTATIVE
  • SR INVOICE & QUALITY CONTROL SPECIALIST

Degrees

  • Bachelor of Science
  • BACHELOR OF SCIENCE

By clicking Customize This Resume, you agree to our Terms of Use and Privacy Policy

*As seen in:As seen in: