Summary
Overview
Work History
Education
Skills
Timeline
Generic

Aleshia Headley

Brooklyn,NY

Summary

Pharmacy operations specialist with proven expertise in claims processing and customer support. Demonstrates strong attention to detail and adherence to HIPAA guidelines, ensuring compliance and quality care. Committed to enhancing service excellence and operational efficiency.

Overview

20
20
years of professional experience

Work History

Customer Care Representative

Capital Rx
New York, New York
11.2020 - Current
  • Triage incoming phone calls from members and pharmacies to identify and resolve issues promptly.
  • Support call center staff, including technicians and representatives, to enhance service quality.
  • Document and escalate member and pharmacy concerns to relevant Operations Team members.
  • Communicate effectively with members, pharmacies, and internal stakeholders to ensure quality care.
  • Maintain high customer satisfaction and compassion while delivering resolutions in a fast-paced environment.
  • Adhere to internal Standard Operating Procedures, HIPAA guidelines, and company policies.
  • Review pharmacy claims for the Fraud, Waste, and Abuse program, reporting findings to staff.
  • Perform additional customer support duties as assigned.
  • Audited patient records to guarantee accuracy of information and thoroughness of documentation for Medicare, Medicaid, and Commercial claims processing.

Pharmacy Operations Assistant

Cognizant Technology Solutions
New York, New York
06.2016 - 11.2020
  • Managed health insurance plans, including Medicaid, Medicare, and commercial programs.
  • Supported Pharmacy Ops Resolution Help Desk with member escalations regarding copayments and benefit inquiries.
  • Allocated member escalation issues between Manila and NY RXHD Service Center.
  • Served as primary contact for EmblemHealth Employee Line to address pharmacy-related issues.
  • Handled benefit escalations, forwarding discrepancies to management for resolution updates.
  • Processed member reimbursements and provider vaccine claims efficiently.
  • Assisted Clinical/Specialty team with member callbacks for prior authorization inquiries.
  • Verified and updated member coverage in system during activation processes.

Pharmacy Operations Assistant

EmblemHealth
New York, New York
01.2013 - 06.2016
  • Managed responses to member, physician, and pharmacy inquiries from Customer Service and Enrollment.
  • Processed member and provider reimbursement claims within defined timeframes while maintaining compliance logs.
  • Provided comprehensive pharmacy support, including file maintenance and audit assistance.
  • Researched sensitive member grievances and coordinated timely responses with Grievance and Appeals department.
  • Maintained communication with pharmacy supervisory staff and trained team members as needed.
  • Monitored pharmacy call center trends using Avaya-CMS Supervisor and reported findings to management.
  • Assisted with high-volume member calls and set up clinical cases during peak periods.
  • Updated MaxMc Medical Management system, generated notices for denied services, and closed cases accordingly.

Peer Advisor Coordinator

ValueOptions, Inc
New York, New York
09.2005 - 06.2012
  • Executed data entry for authorizations to maintain compliance and efficiency.
  • Facilitated administrative support by establishing medical records for retrospective reviews.
  • Sent acknowledgement letters to facilities to confirm receipt of documents.
  • Processed administrative denials, ensuring accurate record-keeping.
  • Drafted denial and fair hearing letters for timely communication with stakeholders.
  • Provided verbal notifications to providers and facilities regarding authorization statuses.
  • Secured protected health information (PHI) in accordance with regulations.
  • Trained new hires on best practices for handling medical records and administrative tasks.

Education

Associate of Arts -

Boricua College
Brooklyn
12-2012

Skills

  • Customer support
  • Claims processing
  • Pharmacy operations
  • Call center management
  • HIPAA compliance
  • Customer relationship management

Timeline

Customer Care Representative

Capital Rx
11.2020 - Current

Pharmacy Operations Assistant

Cognizant Technology Solutions
06.2016 - 11.2020

Pharmacy Operations Assistant

EmblemHealth
01.2013 - 06.2016

Peer Advisor Coordinator

ValueOptions, Inc
09.2005 - 06.2012

Associate of Arts -

Boricua College

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