Andrea Smith
Roseville,MI
Summary
Adept in promoting customer satisfaction and proactive solutions to diverse business needs and concerns. Accurate and organized with good data entry and recordkeeping abilities. A Team player with an analytical mindset. Looking to use subject matter expertize handles more complex issues and respond to escalated calls from peers, members, provider/physician's offices and pharmacies
Overview
22
22
years of professional experience
Work History
Senior Pharmacy Resolution Specialist
Centene Coporation
11.2022 - Current
- Takes member/prescriber/pharmacist inquiry calls for benefit questions including prior authorization requests.
- Offers options including submission of prior authorization request.
- Thoroughly researches issues and takes appropriate action to resolve them using appropriate reference material within turnaround time requirements and quality standards.
- Answers and conducts inbound and outbound calls with members and provider offices to provide resolution to claims (i.e.: additional information requests and medication determination updates).
- Thoroughly researches issues and takes appropriate action to resolve them within turnaround time requirements and quality standards of 95-100% on call audits.
- Assists team members often guiding them to appropriate resolution of more complex and difficult inquiries.
- Participates in training of less experienced staff, including opportunity for job shadowing.
- Liaison between internal departments on data gathering and problem solving while investigating problems of unusual nature in area of responsibility.
- Presents proposed solutions in clear and concise manner.
- Assists with audit preparation as needed.
- Assists with miscellaneous special project work as assigned.
Pharmacy Resolution Specialist
Cenetene Corporation
09.2021 - 11.2022
- · Operate Member/prescriber/pharmacist inquiry calls in regards to benefit question.
- · Answer/ conduct inbound/ outbound calls with Member/prescriber/pharmacist to provide resolutions to various claim rejections.
- · Preform comprehensive research issues and take appropriate actions using various reference materials to find quality results in timely matter.
- · Actively involved in initiation and providing information on status of prior authorization/coverage determination, appeal/ redetermination phone calls.
- · Review clinical supporting documentation to ensure accurate additional information was received for overturn denial decision.
- · Log, track, resolve, and respond to all assigned inquiries and complaints while staying within CMS and Centene Corporate guidelines.
- · Keep abreast with knowledge on all pharmacy benefits and formularies, including CMS regulations.
- · Establish appointments for peer to peer reviews between prescribers and pharmacist to dialog over members medication needs.
- · Maintain overall average call quality of 95-100%
Support Services Representative
Beaumont Service Center
02.2020 - 09.2021
- Verify insurance coverage and obtain information from various provider platforms.
- Review and resolve Denials for Professional and Facility claims.
- Effective liaison between patients and insurances membership/providers lines.
- Update patients account records to reflect actions taken.
- Research accounts to complete appropriate follow up actions that result in account payment and resolution.
- Update Coordination of Benefits and initiate billing to correct primary, secondary or tertiary payor.
- Managed average of 70 accounts daily.
Personal Banker
Fifth Third Bank
12.2014 - 02.2020
- Established rapport with new clients to increase satisfaction and loyalty.
- Conducted detailed financial Interviews for loan needs and financial histories and conveyed information regarding application processes.
- Prepared internal and regulatory financial reports, including balance sheets and financial center statements.
- Performed routine closings, maintained clean, accurate and accessible records and kept close eye on transaction updates throughout each quarter.
- Monitored all company inventory to ensure stock levels and databases were updated.
- Averaged 20 book of business calls to new/current client daily.
Bank Teller
Citizens Bank
07.2012 - 12.2014
- Performed customer transactions for money orders, cashiers checks, deposits and withdrawals.
- Built and strengthened customer relationships by leveraging excellent interpersonal and communication skills.
- Completed highly accurate, high-volume money counts via both manual and machine-driven approaches.
- Reconciled cash drawer and resolved discrepancies.
- Educated customers on use of banking website and mobile apps.
- Learned about customer's financial needs, established trust, and optimized sales opportunities resulting in quality customer service.
Customer Service Representative
Results At Your Fingertips
09.2009 - 07.2012
- Accepted and processed payments and purchases for new equipment.
- Provided accurate information about promotions, customer programs and products, helping drive high customer retention.
- Troubleshot and resolved online ordering issues and concerns to promote seamless ordering process for customers.
- Resolved customer complaints by determining cause of problem, selecting best solution and expediting correction or adjustment.
- Averaged 95-100% call quality.
Claims Adjudicator
Blue Cross Blue Shield Of Michigan
10.2001 - 12.2007
- Determined claim status and negotiated to reach reasonable settlements or denials.
- Used LOCAL and DDE systems to review rejection codes and enter correct data for claims
- Researched prevails screen, ICD9 and CPT to find proper HCPCS, diagnosis and modifiers for correct pricing and payment of various service types.
- Contact Michigan Provider’s to obtain additional information needed to finalize claim.
- Paid or denied medical claims based upon established claims processing criteria.
- Finalized files for insurance claim payment release.
- Spearheaded employee development by assisting coworker with questions on work flow.
Education
No Degree - Business Administration And Management
Baker College
Clinton Township, MIHigh School Diploma -
Denby High School
Detroit, MI06.2000
Skills
- Self-motivated professional
- Coordinate Benefits
- Detail-oriented
- Written and verbal Communication
- Problem Resolution
- Copay/Deductible
Timeline
Senior Pharmacy Resolution Specialist
Centene Coporation
11.2022 - Current
Pharmacy Resolution Specialist
Cenetene Corporation
09.2021 - 11.2022
Support Services Representative
Beaumont Service Center
02.2020 - 09.2021
Personal Banker
Fifth Third Bank
12.2014 - 02.2020
Bank Teller
Citizens Bank
07.2012 - 12.2014
Customer Service Representative
Results At Your Fingertips
09.2009 - 07.2012
Claims Adjudicator
Blue Cross Blue Shield Of Michigan
10.2001 - 12.2007
No Degree - Business Administration And Management
Baker College
High School Diploma -
Denby High School