Provider Relations Representative Resume Example United Health Group

PROVIDER RELATIONS REPRESENTATIVE

Experience

Provider Relations Representative, 08/2016 to 02/2018
United Health Group

Researches and communicates information regarding member eligibility, provider status and authorization inquiries to callers while maintaining confidentiality as well as resolve customer complaints or concerns as the first line of contact.
Makes problem resolution and triage decisions not requiring clinical judgment.
Discourages unnecessary clinical/physician phone transfers and encourages medical records to be submitted.
Help callers understand what clinical information is required.
Transfers calls to clinicians and physicians only for clinically escalated situations.
Actively listens and probes callers in a professional and timely manner to process authorizations and/or other customer service requests working towards first call resolution.
Communicates appeal and denial language to providers and members when appropriate regarding claims & prior authorization cases.
Assist providers with claims notification status as well as provide physicians with information to have claims reprocessed after denying.
Give accurate info to providers so denied claims can be reprocessed and paid.
Provide expertise or general claims support by reviewing, researching, investigating, negotiating, processing and adjusting MEDICAL, DENTAL, PHARMACY, & MENTAL HEALTH claims.
Navigate multiple programs and learn new and complex computer system applications.
Review, analyze and research complex health care claims in order to identify discrepancies, verify pricing, confirm prior authorizations and process them for payment.

Exchange/Returns Customer Service Representative, 09/2015 to 06/2016
IKEA – St. Louis

Work closely with Customer Service Department for Complaint Handling and Customer Feedback logging onto system.
Communicate to customers the generous IKEA Refund Policy and explain all related details in a clear and informative manner.
Handle all Exchange & Refund customer transactions accurately, efficiently and whilst providing highest standards of Customer Service.
Ensure Exchange & Returns Desk is effectively equipped at all times with necessary documents and tools, always available to serve customers throughout the day.
Gain knowledge on how to assemble IKEA products, to assist customers who have difficulties assembling products and exchange component parts when they are needed.
Follow Cash Handling Procedures to ensure accuracy while dealing with transactions.
Utilize information from Exchange & Refund System to detect and act upon or report to management regarding product faults and sales-related issues.
Contribute to the Exchanges and Returns action plan and take ownership for allocated deliverers.
Work in liaison with Department Management to identify solutions to resolve the root cause of customers' return.
Count draw at beginning of shift & Balance draw at the end of shift daily.

Licensed Property & Casualty Insurance Agent, 03/2014 to 07/2015
Rodney D Young Insurance

Provide quotes to customers regarding auto insurance policies.
Calculate premiums and establish payment method.
Explain policies and suggest additions or changes, Bind and process payments for insurance premiums.
Confer with clients to obtain and provide information when claims are made on a policy.
Contact underwriter and submit forms to obtain binder coverage.
Customize insurance programs to suit individual customers, often covering a variety of risks.
Develop marketing strategies to compete with other individuals or companies who sell insurance.
Ensure that policy requirements are fulfilled, including completion of appropriate forms.
Explain features, advantages and disadvantages of various policies to promote sale of insurance plans.
Interview prospective clients to obtain data about their financial resources and needs, the physical condition of the vehicle to be insured, and to discuss any existing coverage.
Perform administrative tasks, such as maintaining records, handling policy renewals, filing policies, and payments.
Seek out new clients and develop clientele by networking to find new customers and generate lists of prospective clients.
Balance office at the beginning and end of shifts daily.
(Using balance sheet & computer system.).
Ensure all cash deposits are dropped off in a timely manner.

Work History

Provider Relations Representative, 08/2016 to 02/2018
United Health Group

Researches and communicates information regarding member eligibility, provider status and authorization inquiries to callers while maintaining confidentiality as well as resolve customer complaints or concerns as the first line of contact.
Makes problem resolution and triage decisions not requiring clinical judgment.
Discourages unnecessary clinical/physician phone transfers and encourages medical records to be submitted.
Help callers understand what clinical information is required.
Transfers calls to clinicians and physicians only for clinically escalated situations.
Actively listens and probes callers in a professional and timely manner to process authorizations and/or other customer service requests working towards first call resolution.
Communicates appeal and denial language to providers and members when appropriate regarding claims & prior authorization cases.
Assist providers with claims notification status as well as provide physicians with information to have claims reprocessed after denying.
Give accurate info to providers so denied claims can be reprocessed and paid.
Provide expertise or general claims support by reviewing, researching, investigating, negotiating, processing and adjusting MEDICAL, DENTAL, PHARMACY, & MENTAL HEALTH claims.
Navigate multiple programs and learn new and complex computer system applications.
Review, analyze and research complex health care claims in order to identify discrepancies, verify pricing, confirm prior authorizations and process them for payment.

Exchange/Returns Customer Service Representative, 09/2015 to 06/2016
IKEA – St. Louis

Work closely with Customer Service Department for Complaint Handling and Customer Feedback logging onto system.
Communicate to customers the generous IKEA Refund Policy and explain all related details in a clear and informative manner.
Handle all Exchange & Refund customer transactions accurately, efficiently and whilst providing highest standards of Customer Service.
Ensure Exchange & Returns Desk is effectively equipped at all times with necessary documents and tools, always available to serve customers throughout the day.
Gain knowledge on how to assemble IKEA products, to assist customers who have difficulties assembling products and exchange component parts when they are needed.
Follow Cash Handling Procedures to ensure accuracy while dealing with transactions.
Utilize information from Exchange & Refund System to detect and act upon or report to management regarding product faults and sales-related issues.
Contribute to the Exchanges and Returns action plan and take ownership for allocated deliverers.
Work in liaison with Department Management to identify solutions to resolve the root cause of customers' return.
Count draw at beginning of shift & Balance draw at the end of shift daily.

Licensed Property & Casualty Insurance Agent, 03/2014 to 07/2015
Rodney D Young Insurance

Provide quotes to customers regarding auto insurance policies.
Calculate premiums and establish payment method.
Explain policies and suggest additions or changes, Bind and process payments for insurance premiums.
Confer with clients to obtain and provide information when claims are made on a policy.
Contact underwriter and submit forms to obtain binder coverage.
Customize insurance programs to suit individual customers, often covering a variety of risks.
Develop marketing strategies to compete with other individuals or companies who sell insurance.
Ensure that policy requirements are fulfilled, including completion of appropriate forms.
Explain features, advantages and disadvantages of various policies to promote sale of insurance plans.
Interview prospective clients to obtain data about their financial resources and needs, the physical condition of the vehicle to be insured, and to discuss any existing coverage.
Perform administrative tasks, such as maintaining records, handling policy renewals, filing policies, and payments.
Seek out new clients and develop clientele by networking to find new customers and generate lists of prospective clients.
Balance office at the beginning and end of shifts daily.
(Using balance sheet & computer system.).
Ensure all cash deposits are dropped off in a timely manner.

Education

General Studies, 12/2013
Forest Park Community College - St. Louis, MO

High School Diploma: 06/2005
Sumner High School - St. Louis, MO

Summary

Reliable, goal-oriented, adaptive team player seeking a position in an established medical office or facility supporting, medical staff to expedite patient care. Compassionate, outgoing customer service representative aiming to use my proven skills in healthcare to progress in the healthcare field.

Highlights

Data Entry, Medical Terminology, Claims Processing Microsoft Products, Windows System Intake/Pre-Certification, Procedure Codes, Filing JavaScript, Claims Resolution, Health Insurance,
Multi-Line Software, Researching, Documentation Office Administration, Conflict Resolution Pricing, Opening/Closing Procedures, Scheduling Communication Skills, Reimbursement Policies
Customer Service, Multi-tasking, Billing Cash Handling, Typing (30-35wpm)
Administrative, Pricing
Balance sheet, Problem resolution
Balance, Researching
Billing, Research
Bind, Sales
Binder, Scheduling

Cash deposits, Phone
Cash Handling, Triage
Closing, Typing
Communication Skills, 35wpm
Conflict Resolution, Underwriter
Draw
Resolve customer complaints
Clientele
Clients
Customer Service
Data Entry
Documentation
Features
Filing
Financial
Forms
Insurance
JavaScript
Logging
Marketing strategies
Medical Terminology
MENTAL HEALTH
Microsoft Products
Exchange
Office
Windows
Multi-tasking
Negotiating
Networking
Office Administration
Policies

Skills

Administrative, balance sheet, Balance, Billing, Bind, binder, cash deposits, Cash Handling, Closing, Communication Skills, Conflict Resolution, draw, resolve customer complaints, clientele, clients, Customer Service, Data Entry, Documentation, features, Filing, financial, forms, Insurance, JavaScript, logging, marketing strategies, Medical Terminology, MENTAL HEALTH, Microsoft Products, Exchange, office, Windows, Multi-tasking, negotiating, networking, Office Administration, Policies, Pricing, problem resolution, Researching, research, sales, Scheduling, phone, triage, Typing, 35wpm, underwriter

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Provider Relations Representative Resume Example

Resume Score: 90%