Alyssa Toner
Mesa,AZ
Summary
Exceptionally qualified professional with people management and leadership skills that yield high-performing teams with dedication to quality and service standards. Possesses the ability to create and conduct an inclusive environment with focus on improving efficiency and effectiveness. Leading with collaboration and active listing skills to help focus on team and company goals. Dedication to growing skill sets in technology and storytelling data that helps meet and exceed expectations of organizational needs. Possesses conflict resolution with solution-oriented skills that yield optimum results with empathy and compassion.
Overview
12
12
years of professional experience
Work History
Clinical Concierge Specialist
Oscar Health
Tempe, AZ
06.2018 - 08.2025
- Maintained personal relationships with hospitals providing effective resources for discharge planning needs of patient's
- Navigated through patient clinicals to determine appropriate needs and care with collaboration of case managers and social workers
- Abide by HIPPA compliance and confidentiality
- Assessed and analyzed claims in accordance to established polices
- Managed a caseload of claims, ensuring timely resolution and member satisfaction
- Collaborated with internal departments to investigate and verify claim information
- Prepared and presented reports on claim status and trends
- Assisted member submitted claims
- Navigated providers on claim status and appeal processes if applicable
- Triaging Medical/Operational referrals from Transplant, Behavioral Health, Rare Diseases, Oncology, Case Management
- Participated in a transplant pilot program, successfully executing new workflows for transplant contract processing with Cigna LifeSource and Optum.
- Assisting with different medical request, print request, SCA/COC/DME researching and resolutions.
- Partnering with 3rd party referrals providing exceptional member experience
- Supporting and partnering with Registered Nurses and other clinical providers to ensure high level of member experience regarding complex needs, triaging acute inpatient alerts with case management escalations, triaging and resolutions.
- Helping assisting members with complex clinical information and escalations regarding coverage policy and navigating Healthcare Systems
- Organizes workload, set priorities, complete assignments in a timely manner and utilize resources appropriately while complying with department program standards.
- Ability to adapt to ambiguous environments and processes that support departments quality and new processes.
- Navigating difference internal and external resources to help identify resolutions for members needs regarding Benefits, Cost Share, Copays, In-Network Providers as well as authorization request and statuses.
- Demonstrates ability to maintain productive working relationships with clinical and non-clinical team members, other internal and external customers as well as management team.
- Able to apply and conduct a logical approach to member inquiries to arrive at fact-based solutions.
- Excellent communication skills (verbal and written) via phone, in person, and e-mail in a professional and friendly manner.
- Able to communicate clinical information to internal partners and members.
Manager Team Lead / Customer Service Rep
GC Services
Mesa, AZ
10.2013 - 05.2018
- First point of contact for incoming calls regarding account information or order inquires.
- Resolving customers inquires in an efficient and timely manner.
- Acted as a Subject Matter Expert of Team, maintain high quality control, customer service satisfaction.
- Point of contact for escalations regarding any members concerns and/or complaints.
- Coached and mentor team focusing and developing them on their daily activities, customer service skills, and professionalism in the workplace.
- Focused on Quality Assurance of Team Members with shadowing and real time feedback.
- Providing timely and accurate responses and/or guidance to team members inquires.
- Monthly and Annual performance reviews delivering coaching, feedback and difficult conversations to underperforming employees.
- Approved PTO/Sick time off request, attendance tracking, payroll and other administrative responsibilities including Corrective Action Plans (CAPs), Performance Improvement Plans (PIPs) and termination.
- Delivered coaching, weekly meetings regarding updates and new directives of departmental goals.
- Collaborated with the care team on coordination of safe transitions of care for a defined customer population.
- Ensured adherence new and existing KPI's on team ensuring adherence to team's goals.
- Track performance utilizing Excel and other software tools.
- Weekly call calibrations with client to discuss progress, trends, agent reports
Education
Mesa Community College
Mesa, AZSkills
- Medical Terminology
- Slack
- Microsoft Office
- Google Suite
- Workday
- Okta
- Optum portal
- CVS Caremark
- People Soft
- Claims processing & Resolution
- Complaint Resolution & De-escalation Techniques
- Call Center- High Volume Customer Support
- Provider & Pharmacy Relations
- Care Coordination & Discharge Follow-up
- Health Insurance Education & Knowledge
- Payment Processing & Billing Support
- Team Development & Training
- Patient Scheduling
Achievements And Skills
- GC Services Top Gun Award, 2014
- Recognized top performer in STATS, adherence, number of outreaches completed, quality in calls
- EHR/EMR Systems (Epic, eClinicalWorks, Allscripts – familiar)
- Proficient in Medical Terminology, Technology Skill Sets: Slack, Microsoft Office, Google Suite, Workday, Okta, People Soft
- CRM & Call Center Platforms
- Payment & Claims Systems
- Multi-line Phone Systems
Timeline
Clinical Concierge Specialist
Oscar Health
06.2018 - 08.2025
Manager Team Lead / Customer Service Rep
GC Services
10.2013 - 05.2018
Mesa Community College