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Jessica Claire
, , 100 Montgomery St. 10th Floor
Home: (555) 432-1000 - Cell: - resumesample@example.com - -
Summary

Over ten years of experience in supervision and customer service. Direct experience with management of small cells, and larger groups. Highly motivated, outgoing individual who works well independently, and within a team. Excellent organizational, communication, and interpersonal skills obtained through education and work environments.

Skills
  • Insurance claims management
  • Excellent telephone etiquette
  • Exceptional patient care and interaction
  • HIPAA trained
  • Expert understanding of Medicare and Medicaid processes
  • Supervisory skills
  • Prior Authorization experience
  • Efficient and detailed
Experience
01/2018 to Current
Pharmacy Medical Claims Specialist Lampert Lumber Sister Bay, WI,
  • Obtain/verify insurance eligibility for services provided and document information in CareTend system.
  • Verify prior authorization approval is on file via PEAR portal for Medical Benefit, verification of correct procedure codes, units, effective dates correlate with prescription received.
  • Submit prior authorization requests to prescriber's offices.
  • Collect any clinical information such as lab values, diagnosis codes, medical necessity, doctor's notes, and procedure codes.
  • Determine patient's financial responsibilities as stated by insurance via PEAR portal.
  • Document all pertinent communication with patient, physician, insurance company.
  • Identify and coordinate patient resources as it pertains to reimbursement, such as copay cards, third party assistance programs, and manufacturer assistance programs.
  • Receive/make inbound/outbound calls to patients, physician offices, and/or insurance companies.
  • Responsible for the timely submission of claims, electronic and paper as needed to payers corrects and resubmits rejected claims.
  • Post insurance checks while ensuring services were paid correctly and correct patient responsibility was collected or copay/financial assistance programs were billed.
01/2015 to Current
Assistant Manager Eargo, Inc. San Jose, CA,
  • Took necessary steps to meet guest needs and effectively resolve food service issues.
  • Oversea daily operations and set up store for events.
  • Enforce food safety guidelines (HAACP) and ServSafe certified.
  • Delegated daily tasks to team members to optimize group productivity.
  • Secured revenue, accurately monitoring transactions and deposits to eliminate discrepancies.
  • Developed training, assessment and performance monitoring programs to coach and mentor employees.
09/2017 to 01/2018
Pharmacy Medical Claims Specialist Apollo Medical Holdings, Inc. Alhambra, CA,
  • Obtain/verify insurance eligibility for services provided and document information in CareTend system.
  • Verify prior authorization approval is on file via PEAR portal for Medical Benefit, verification of correct procedure codes, units, effective dates correlate with prescription received.
  • Submit prior authorization requests to prescriber's offices.
  • Collect any clinical information such as lab values, diagnosis codes, medical necessity, doctor's notes, and procedure codes.
  • Determine patient's financial responsibilities as stated by insurance via PEAR portal.
  • Document all pertinent communication with patient, physician, insurance company.
  • Identify and coordinate patient resources as it pertains to reimbursement, such as copay cards, third party assistance programs, and manufacturer assistance programs.
  • Receive/make inbound/outbound calls to patients, physician offices, and/or insurance companies.
  • Responsible for the timely submission of claims, electronic and paper as needed to payers corrects and resubmits rejected claims.
  • Post insurance checks while ensuring services were paid correctly and correct patient responsibility was collected or copay/financial assistance programs were billed.
01/2016 to 08/2017
Insurance Verification Coordinator Apollo Medical Holdings, Inc. Monterey Park, CA,
  • Obtain and verify insurance eligibility for services provided and document complete information in system.
  • Perform prior authorizations as required by payor source, including procurement of needed documentation by collaborating with physician offices and insurance companies.
  • Collect any clinical information such as lab values, diagnosis codes, etc.
  • Determine patient's financial responsibilities as stated by insurance.
  • Configure coordination of benefits information on every referral.
  • Document all pertinent communication with patient, physician, insurance company as it may relate to collection procedures.
  • Identify and coordinate patient resources as it pertains to reimbursement, such as copay cards, third party assistance programs, and manufacturer assistance programs.
  • Handle inbound calls from patients, physician offices, and/or insurance companies.
  • Resolve claim rejections for eligibility, coverage, and other issues.
08/2015 to 01/2016
Member Services Representative Archcare Tarrytown, NY,
  • Assisted hospice nurses with questions regarding prescription drug benefits, medication coverage, and hospice formulary.
  • Worked with a dual monitor system, received calls, as well as worked faxes regarding hospice patients medication lists and medical history.
  • Added/discharged patients using systems such as RxClaims and HospiDirect - added medications, medication directions, and medical history.
  • Assisted pharmacies with processing information.
  • Initiated claims reversals and overrides for non-formulary medications.
  • Provided outstanding customer service to every caller and worked to resolve escalated situations.
03/2014 to 11/2014
Member Services Representative Exos Seattle, WA,
  • Assisted hospice nurses with questions regarding prescription drug benefits, medication coverage, and hospice formulary.
  • Worked with a dual monitor system, received calls, as well as worked faxes regarding hospice patients medication lists and medical history.
  • Added/discharged patients using systems such as RxClaims and HospiDirect - added medications, medication directions, and medical history.
  • Assisted pharmacies with processing information.
  • Initiated claims reversals and overrides for non-formulary medications.
  • Provided outstanding customer service to every caller and worked to resolve escalated situations.
10/2013 to 01/2014
Member Services Representative Enjoy Boca Raton, FL,
  • Assisted Medicare members with questions regarding their prescription drug benefits.
  • Initiated prior authorizations by obtaining information from the physician's office.
  • Assisted pharmacists with processing information.
  • Initiated claims reversals and sent out member reimbursements.
  • Contacted escalated Medicare members and assited with the resolution process.
  • Helped to establish and track members in the RxClaims and Navigation systems and initiated their eligibility.
  • Performed override functions on a plan to plan basis.
  • Provided outstanding customer service to each member.
12/2008 to 04/2013
Assistant General Manager Wetzel's Pretzels/Häagen-Dazs (Disney Springs) City, STATE,
  • Took necessary steps to meet guest needs and effectively resolve food service issues.
  • Oversea daily operations and set up store.
  • Enforce food safety guidelines (HAACP) and ServSafe certified.
  • Delegated daily tasks to team members to optimize group productivity.
  • Secured revenue, accurately monitoring transactions and deposits to eliminate discrepancies.
  • Developed training, assessment and performance monitoring programs to coach and mentor employees.
  • Supervised critical tasks, including budget implementations, employee reviews, training and scheduling.
  • Disciplined and maintained staff to deliver hospitable, professional service reflecting business initiatives.
08/2005 to 01/2008
Team Captain Universal Studios Orlando City, STATE,
  • Set up registers, ordered change, based tills, processed deposits, cashed out drawers, and pulled paperwork at the end of the shift.
  • Held accountable for supervision of 20+ staff members during any given shift.
  • Assisting hundreds of guests daily, turning unsatisfied customers into guests who would happily return again.
  • Cross training team members and supplying them with coaching needed to succeed.
  • Worked closely with team members to set up production lines.
  • Communicated with department supervisors and managers to establish objectives and monitor performance of team members based on established KPI metrics.
Education and Training
Expected in 05/2002
High School Diploma: CNA
Swain County High School - Bryson City, NC
GPA:

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Resume Overview

School Attended

  • Swain County High School

Job Titles Held:

  • Pharmacy Medical Claims Specialist
  • Assistant Manager
  • Pharmacy Medical Claims Specialist
  • Insurance Verification Coordinator
  • Member Services Representative
  • Member Services Representative
  • Member Services Representative
  • Assistant General Manager
  • Team Captain

Degrees

  • High School Diploma

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