Montgomery Street, San Francisco, CA94105609 Johnson Ave., 49204, Tulsa, OK
Home: (555) 432-1000
Cell:
resumesample@example.com
Career Overview
I am looking forward to becoming part of a team that offers potential growth, stability and advancement opportunities.
Work Experience
PDM - Network Data Specialist II, 2014 to Current Tata Consultancy Services – Miami, FL,
Completes the setup and maintenance of new provider information to effectively administer the operational requirements of current and new business.
Completes research and suggests resolutions for more complex quality issues, and applies expanded knowledge of state-specific provider data requirements to mentor entry level team members and ensure effective administration of core business requirements.
Completes Provider Data Management tasks which include but are not limited to establishing new participating provider records, processes provider roster terminations, adding network and capitation rows, and corrects data quality issues.
Applies expanded knowledge of state-specific provider data requirements to mentor entry level team members and ensure effective administration of core business requirements.
Works with management and team members in the provider configuration and implementation of all approved market specific or global projects to include existing market expansion, new market or business activities, acquisition activities and system design initiatives.
Conducts research and analysis of complex provider data quality issues and acts to resolve them in a timely fashion.
Observes trends in provider data quality issues and makes proactive suggestions for proactive resolution.
Communicates with provider organizations to request and validate provider information and facilitate proactive resolution of issues.
Actively maintains a positive customer relationship with the health plan staff, sharing feedback with management and identifying process improvements.
Serves as a mentor for entry level team members as needed; trains new Specialists and temporary associates.
Meets or exceeds individual and department productivity metrics, quality, and timeliness standards as defined by department guidelines.
Performs other duties as assigned or requested.
Provider Services Unit, 03/2012 to 2014 Amerigroup Corp – City, STATE,
Under general direction, provides assistance to members, providers, or others inquiring about eligibility, claims issues, and product information or experiencing customer service problems.
Determines callers needs and provides the pertinent information or researches and resolves their issue appropriately.
At times, may be required to assist junior representatives on escalated issues.
Provides telephonic assistance to members, providers, billing agencies and/or prospective members for assigned products.
Assists with benefit and eligibility explanation, claim issues, network changes, customer service issues and/or terminations.
Prepares correspondence, maintains phone and contact logs, and documents call details as appropriate.
Identifies trends and root causes of call inquiries or issues, and recommends improvements to internal processes and training to department leadership.
Understands and accurately interprets product benefits, applicable state and federal guidelines/regulations, and department policies.
Assesses caller's needs, makes appropriate recommendations or action, and aims for first call resolution.
Resolves complex or escalated issues of callers by thoroughly researching cause of error.
Customer Care Rep, 03/2010 to 03/2012 Amerigroup Corp – City, STATE,
Responsible for responding to either inbound inquiries or outreach calls from/to potential and existing Amerigroup members and providers.
Responsibilities include providing accurate information/education/resolution about eligibility status, benefit coverage, provider network, credentialing status, authorization/referral status, demographic changes and all other non-claim issues.
Function as an information source through telephonic assistance to members, providers, billing agencies, and various company/department staff.
Provide pleasant customer experience through superior customer service methods, problem solving and real-time issue resolution.
Interact with provider community and various departments to resolve issues involving the membership and credentialing status.
Explain benefits, eligibility status, enrollment processing procedures and status of authorizations and referrals to callers.
Assist with activities to ensure membership's continuity of care.
Conduct member outreach calls as assigned to proactively educate members on services available (Welcome Calls), complete health assessments for plan case management (Early Case Findings and Healthy Beginnings) and conduct membership surveys.
Process complaints, following established guidelines.
Maintain knowledge of state guidelines, regulations, and departmental policies and practices and maintain accurate documentation for compliance.
Educational Background
High School Diploma: , Expected in 1995 Midlothian High School - Richmond, VA GPA:
Accredit for Business Computer Applications, Office Administration and
Basic/Advance Accounting.
Languages
English
Skills
Technical skills in Business Computer Applications with Basic and Advanced
Accounting techniques.
Skills in Word Processing, Microsoft Office Excel, Spreadsheets, Data Entry,
Word Optimization / Search Engines Optimization, Microsoft Internet Explorer,
MACESS, FACETS and EDINET.
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