Adrien Jones
Savannah,GA
Summary
To seek and maintain full-time position that offers professional challenges utilizing interpersonal skills, excellent time management and problem-solving skills. Self-motivated Sr coordinator brings proven leadership, organizational and customer relations skills. Independently solves problems and keeps teams on task to handle diverse business requirements. History retaining members and talented staff.
Overview
18
18
years of professional experience
Work History
Sr Complaint & Appeal Coordinator
Aetna/CVS Health
09.2022 - Current
- Handle member complaint and appeals, prep and launch clinical and nonclinical cases, and close before due date. Uses systems such as CATS, Novologix, Stars referral system, ATV, Medcompass, Evicore, IOP, ECHS, McKesson, EWMP, EPDB, ACAS Rumba, CAS system. GPS system, ASD, PSPP/PST, Web CCI, SCM, QuickBase.
- Improved team productivity with regular communication and progress updates, fostering collaborative work environment.
- Enhanced operational workflows by maintaining well-organized documentation systems and updating records accurately as needed.
- Enhanced customer satisfaction by responding promptly to inquiries and addressing concerns professionally.
- Resolved issues through active listening and open-ended questioning, escalating major problems to manager.
- Kept high average of performance evaluations.
- Mentor new hires.
Sr Claims Benefit Specialist
Aetna/CVS Health
07.2021 - 09.2022
- Reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with claim processing guidelines
- Subject matter expert by providing training, coaching, or responding to complex issues
- Reviews pre-specified claims or claims that exceed specialist adjudication authority or processing expertise
- Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist with claim adjudication process
- Ensures all compliance requirements are satisfied and that all payments are made against company practices and procedures
- Identifies and reports possible claim over payments, underpayments and any other irregularities
- Performs claim re-work calculations
- Distributes work assignments daily to junior staff
- Trains and mentors claim benefit specialists
- Works with Health Plan Operations and within State Encounter system to research and resolve errors.
Quality Auditor
Blue Cross And Blue Shield of Florida
09.2018 - 03.2020
- Audited high dollar claims to ensure that claims processed correctly per member benefits
- Verified eligibility, authorization, provider contract, pricing per effective date of provider contract.
- Trained new Quality Auditors on best practices, increasing their proficiency in performing audits effectively.
- Participated in cross-functional team meetings, contributing valuable insights from auditor's perspective to facilitate process improvements.
- Identified discrepancies in product specifications and collaborated with engineering teams to resolve issues.
Service Advocate IV
Blue Cross and Blue Shield of Florida
08.2016 - 09.2018
- Assisted with membership, billing, enrollment, eligibility, benefits, training new hires, processed claims to ensure that claims processed correctly per member benefits
- Answered general inquiries in reference to incorrectly processed claims.
- Enhanced client retention through exceptional service delivery and proactive communication.
- Analyzed customers' issues and complaints and initiated corrective actions.
- Maintained detailed knowledge of company products and services to provide accurate information to clients.
- Handled escalations professionally, demonstrating composure under pressure while finding satisfactory solutions for both parties involved.
- Exceeded performance metrics consistently by prioritizing tasks effectively and efficiently.
- Documented calls accurately, maintaining organized records for future reference or escalation purposes if needed.
- Managed high call volumes while maintaining quality service standards and positive customer interactions.
Collections Agent
ERC
06.2015 - 08.2016
- Worked in office setting, stay on phones to collect payments from customers, followed procedures.
Store Clerk
Gate Petroleum Jacksonville
01.2014 - 06.2015
- Customer service was high demand, making sure coffee was made, store cleaned, outside store clean, inventory, stocking coolers, making sure all products were in date.
MHT
Phoenix Center Behavioral Health Services
04.2010 - 04.2011
- Supervised 10 substance abused women in state facility home setting, completed weekly drug test, logged daily activities of patients progress in catalyst, drove patients to designated appointments in state vehicle.
Assistant Manager
Buger King
07.2006 - 04.2009
- Responsable for supervising 4-8 employees, verified money in safe, inventory, bank deposits, assisted with hiring new employees
Education
Technical Certificate in Office Administration - Secretarial Studies And Office Administration
Florida State College At Jacksonville
Jacksonville, FL12.2017
No Degree - Psychology
Georgia Military College
Warner Robins, GA12.2014
Skills
- Quality Management
- Work Planning and Prioritization
- Relationship Building
- Presenting Ideas and Plans
- Process Improvement
- Best Practices Implementation
- Professional Networking
- Multitasking and Organization
- Team Leadership
- Coaching and Mentoring
- Handling Complaints
Timeline
Sr Complaint & Appeal Coordinator
Aetna/CVS Health
09.2022 - Current
Sr Claims Benefit Specialist
Aetna/CVS Health
07.2021 - 09.2022
Quality Auditor
Blue Cross And Blue Shield of Florida
09.2018 - 03.2020
Service Advocate IV
Blue Cross and Blue Shield of Florida
08.2016 - 09.2018
Collections Agent
ERC
06.2015 - 08.2016
Store Clerk
Gate Petroleum Jacksonville
01.2014 - 06.2015
MHT
Phoenix Center Behavioral Health Services
04.2010 - 04.2011
Assistant Manager
Buger King
07.2006 - 04.2009
Technical Certificate in Office Administration - Secretarial Studies And Office Administration
Florida State College At Jacksonville
No Degree - Psychology
Georgia Military College
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