Bernadine Newman
Senior Customer Resolution Specialist
Spring Valley,NV
Summary
Experienced Customer Service Specialist with over 10 years of experience, bringing top-notch skills in oral and written communication, active listening and analytical problem-solving skills. Enhances customer experiences by employing service-oriented behaviors, understanding customer desires and providing customized solutions to build loyalty.
Overview
14
14
years of professional experience
Work History
Healthcare, HEDIS Coordinator II (Contract)
Elevance Anthem BlueCross
Las Vegas, NV
01.2023 - 05.2023
- Direct outreach to over 80 medical providers per day via phone, fax, or EMR systems to obtain medical records of patients for quality review of treatment received.
- Coordinated health information requests with Release of Information Department specialists via secured systems via fax, email, or dedicated EMR systems.
- Performed Medical record chart retrieval between client and EMR service providers (scan stat, EPIX ROI etc........) to ensure information requested and received was relevant to patient/member charts per CMS, HHS protocol, and NCQA guidelines
- Queried tracked and identified relevant medical records within the document management system, care management system, and vendor(s) databases to be uploaded into secured databases of patient medical records per HIPPA guidelines.
- Tracked in-house retrieval requests to ensure receipt of information requested by generating reports and producing tracking documentation.
- Managed and tracked office activities by maintaining communication between providers tracking records, and filing all documents uploaded.
- Interpreted management directives to define and document administrative staff processes by maintaining communication between providers for any issues or concerns.
Anthem Health Guide Specialist (Contract)
Anthem Blue Cross CA Large Group
Las Vegas, NV
06.2021 - 01.2022
- Served as the primary source of contact providing concierge level of service group of insured clients for California State employees, via inbound or outbound calls handling over 70 calls and resolving routine questions regarding policy benefits, provider contracts, eligibility, claims
- Researched and analyzed data across multiple systems to provide tailored solutions to each client with one-call resolution
- Educated insured as to how to maximize their health insurance benefits
- Filed grievances or appeals, resubmissions of claims and coordinated with various departments regarding customer requests or complaints to ensure
Claims Adjudicator(Contract)
Unemployment Claims Adjudicator Maximus INC for State of AZ
Las Vegas , NV
12.2020 - 03.2021
- Evaluated and processed over 200 claims in accordance with state policies procedures and quality standards.
- Reviewed and analyzed data from system-generated reports for in-process claims to identify and resolve errors prior to final adjudication
- Assists claimants, providers, and clients with problems or questions regarding their claims and/or policies
- Enters codes and verifies data for computer processing
- Prepares and prints drafts for payment of claims, denials, and overpayment requests and notified claimants of decisions.
- Proved successful working within tight deadlines and a fast-paced environment.
Customer Service Advocate
CVS Health
Las Vegas, NV
10.2020 - 02.2021
- Inbound call assisting over 80 calls daily from prescribers with understanding prescription insurance, medication coverage, and mail-order prescriptions.
- Performed plan overrides for continued prescription coverage such as lost medication, or being out of the country on a case-by basis.
- Explained aspects of prescription drug plans to clients
- Performed overrides and PA (prior authorizations) for members to receive medications.
- Updated and notated clients' profiles per each call
Health Insurance Enrollment Rep(Contract)
Humana, C3
Las Vegas, NV
06.2020 - 10.2020
- Outbound calls to over 90 healthcare Care Facilities, Doctors' Office, and other medical professionals to verify the accuracy of of online directory for enrolled members access.
- Verified and updated databases of information in real time per providers' directives.
Customer Service Relations(Seasonal)
William Sonoma
Las Vegas, NV
11.2013 - 05.2015
- Demonstrated exceptional product knowledge to effectively address customer inquiries and provide accurate information about various products.
- Provided shipping information on customer orders by accurately and efficiently tracking packages and communicating delivery status.
- Checked inventory database to ensure the availability of products and promptly issued replacements or credited customers for damaged or defective merchandise.
- Employed tactful negotiation techniques to resolve customer issues and ensure their satisfaction within established company guidelines.
- Processed written correspondence, including emails and letters, in a timely manner to maintain effective communication with customers.
- Operated in dynamic, high-volume environments to provide skilled assistance to more than 80 customers each day
Eligibility Specialist II(Contract)
Sutter Health and Physicians Hospital
Sacramento, CA
02.2011 - 08.2013
- Processed updated and activated eligibility of client's health insurance for per employer enrolment plans.
- Corrected CPT codes and resubmitted claims per provider instructions
- Retrieved Explanation of Benefits and educated insured of benefits paid and co-pays that were still outstanding.
- Retrieved tracer responses from insurance companies for incorrect coding of procedures or diagnosis
- Responsible for posting refunds and adjustments for all insurance types.
- Researched and identified misapplied payments to providers
- Verified insurance benefits for employees and corrected enrollment errors.
Advisor/ Eligibility Worker II
State of TX Health and Human Services, Texas Work
Houston, TX
09.2009 - 05.2010
- Responsible for interviewing or reviewing and processing up to 300 client's applications to determine or verify eligibility or continued eligibility and benefit level.
- Accurately determined eligibility for clients applying for Federal Aided programs, Medicaid, TANF SNAP/food stamps
- Interviewed clients, documented information gathered, determined benefits, verified case data, explained program benefits and requirements
- Collected and verified all income resources to ensure eligibility of programs applied for within program guidelines
- Processed changes to client status, overpayments, and adjusted or restored benefits.
- Processed and certified documents for accuracy and compliance with government regulations
Education
High School Diploma -
Capitol Senior High School
Baton Rouge, Rouge, LA. LAAssociate of Arts - Accounting
Delta College of Arts & Technology
Baton Rouge, LAHealth Information Technology Certification - undefined
Houston Community College
Houston, TXSkills
- SKILL SET:
- Over 10 years of combined Healthcare and Customer Service experience
- Background with Prior Authorization, Insurance Verification, Medical Billing, Referrals, Copay, Deductibles, Claims, Eligibility, Benefits, and Grievance and Appeals
- Strong knowledge of medical terminology and familiarity with third-party insurance, Medicare, Medi-Cal, Medicaid, and HMO
- Ability to work in a fast-paced environment averaging 90 to 100 calls per day
- Adept and detail-oriented with excellent verbal and written communication
- Microsoft Office programs
- File and Data Retrieval Systems
- Assignment and Project Coordination
- Work Planning and Prioritization
- Regulatory Compliance
- Microsoft Office
- Customer Service Management
- Correspondence and Reports
- Verbal and Written Communication
- Autonomous and Self-Directed
- Research and Analysis
- Data Analysis and Modeling
- CRM Software
Timeline
Healthcare, HEDIS Coordinator II (Contract)
Elevance Anthem BlueCross
01.2023 - 05.2023
Anthem Health Guide Specialist (Contract)
Anthem Blue Cross CA Large Group
06.2021 - 01.2022
Claims Adjudicator(Contract)
Unemployment Claims Adjudicator Maximus INC for State of AZ
12.2020 - 03.2021
Customer Service Advocate
CVS Health
10.2020 - 02.2021
Health Insurance Enrollment Rep(Contract)
Humana, C3
06.2020 - 10.2020
Customer Service Relations(Seasonal)
William Sonoma
11.2013 - 05.2015
Eligibility Specialist II(Contract)
Sutter Health and Physicians Hospital
02.2011 - 08.2013
Advisor/ Eligibility Worker II
State of TX Health and Human Services, Texas Work
09.2009 - 05.2010
High School Diploma -
Capitol Senior High School
Associate of Arts - Accounting
Delta College of Arts & Technology
Health Information Technology Certification - undefined
Houston Community College
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