BRIANNA HARRIS

• Resolve incoming calls concerning member's eligibility, benefits, provider information, monthly premium billing, clinical and pharmacy needs
• Compose routine and non-routine correspondence to answer benefits/provider inquiries in writing
• Coordinate membership changes such as member's primary care physician
• Perform routine to mid-level inventory reduction (i.e., member inquiries, may initiate claim adjustments, respond to emails, etc.)
• Review and analyze member claims for accuracy as well as member education on how benefits are applied
• Participate in quality and efficiency workgroups to continuously improve quality member/customer satisfaction as requested
• Proactively analyze available programs, determine program eligibility and connect the Member to appropriate BSC vendors, Health Advocates, Social Workers, Pharmacy Techs, and Pharmacists. Verify the member is included in or targeted for any outreach or care gap programs and connect members to programs or services when appropriate. Engage members with their wellness plan options
• Comprehensive resolution of pharmacy calls concerning benefits coverage, co-pays, formulary coverage, vacation overrides, and utilization management requirements
• Provide prescription-related benefit coverage (e.g. explanation of coverage or benefit summary related): Provide prescription co-pays. Provide prescription formulary coverage information and utilization management requirements using web-posted printed formulary. Provide a brief description of coverage denial reasons and alternatives listed in the printed formulary. Perform prescription claim overrides
• Provide deductible and max out of pocket information
• Provide status of a prior authorization requests
• Assist members may when and how to appeal a coverage decision
• Other duties as assigned

• Provided feedback on proposed changes that would affect disability benefits programs.
• Maintained accurate records of all activities associated with each claim.
• Participated in training sessions designed to improve knowledge of current policies and procedures.
• Investigated discrepancies between submitted documents and actual circumstances of a case.
• Assisted claimants in obtaining necessary records from medical providers or other sources.
• Drafted correspondence related to the decision-making process on disability claims.
• Analyzed information gathered by investigations and reported findings and recommendations.

• Effective management, maintenance, and protection of patient medical information utilizing electronic medical records system
• Provides support to patients, physicians, other clinic staff, internal and external laboratory and imaging staff, family members, hospital staff, and vendors by offering customer service, communications, and appropriate distribution of information.
• Performs variety of other duties including but not limited to preparing and processing medical information into EMR system by, scanning, batch scanning, quality checks, post scanning, and research.
• Does clerical work, special projects, or float to other facilities as needed and requested to support daily clinic operation goals, bench marks, and quality patient care initiatives per departmental guidelines.
  

• Maintained patient databases and updated information in alignment with HIPAA protocols.
• Pulled charts and prepared for nurse and doctor assessment.
• Managed master calendar and scheduled appointments for providers based on optimal patient loads and clinician availability.
• Handled office inventory by ordering new supplies and scheduled equipment services and repairs.
• Customer service, communication, and appropriate distribution of phone calls and messages
• Appointment times utilizing electronic practice management system.
• Perform other clerical duties as needed and requested to support daily clinic operation goals, bench marks, and quality patient care initiatives per departmental guidelines.
• This position may have access to third party credit card information and transactional systems (cash registers, point of sale devices, applications supporting credit card transactions, and reports or other documents containing credit card information)
• Customer service contact for our patients, physicians, other clinic staff, hospital staff, patient family members, and vendors by offering customer service, communication, and appropriate distribution of phone calls and messages.
• Pulled charts and prepared for nurse and doctor assessment
• Maintained patient databases and updated information in alignment with HIPAA protocols
• Maintained current and accurate medical records for patients
• Aided with prescription refill requests
• Used Cerner to schedule appointments for doctor visits and procedures

• Knowledge of wide array of insurance types such as; government -contracted , employer sponsored, Medicare Part A&B , commercial and private
• Heavy clerical duties such as faxing, emailing, following up via phone, ability to multitask with no distractions
• Services incoming callers (providers/members) for all lines of business in clear professional and accurate manner ,while demonstrating independent critical thinking and problem solving skills
• Documents all calls relating to claims, general questions, & correspondence retrievals
• Ability to actively listen to inquiries while asking all necessary questions for overall comprehension of issue
• Clarifies health insurance coverage for coordination of benefits to process claims.
• Able to handle issues of high complexity in high volume setting.
• Contributes to team goals in achieving organizational objectives.
• Able to identify network status of providers and health care facilities.
• Complied and reviewed medical charts.
• Reviewed daily care slips for doctors.
• Resolved conflicts and negotiated mutually beneficial agreements between parties.

• Handled 50-60 calls per day
• Inbound call center setting with average of 40-50 calls per day / 10 outbound calls or scheduled appointments
• Initiates calls to Veterans to educate them on their health care options and choices
• Each out to health care professionals in community to coordinate medical appointments and follow-up care needs for Veterans
• Follows processes of Department of Veterans Affairs (VA) program and perform all tasks in courteous and professional manner
• Protect health care privacy of patients by strictly following HIPAA regulations to maintain patient confidentiality
• Research systems to find missing information; coordinate with other departments to resolve issues
• Facilitates communication between patients and doctors, medical staff and administrative staff
• Works in variety of technologies to perform required tasks on dual screen monitors
• Anage prioritized tasks in time-sensitive environment.
• Builds authorizations based on referrals, adding correct ICD 10 codes.
• Knowledgeable in many health care specialties including Mental Health, Physical Therapy, Cardiology, Endocrinology , Home Health , Audiology and benefit limitations
• Reviewed daily care slips for doctors.
• Compiled and reviewed medical charts.
• Reviewed and corrected claim errors to facilitate smooth processing.
• Knowledge of types of insurance such as HMO, PPO, Medicare and Medical /benefits and eligibility
• Reconciled data in direct collection system with accounting system to address discrepancies
• Followed up with insured individuals regarding premium and deductibles payments
• Reviewed field inspections and coordinated all insurance claim audits.
• Examined claims forms and other records to determine insurance coverage.
• Identified key areas not performing well and implemented effective new techniques.

• Followed up on potentially fraudulent claims initiated by claims representatives.
• Managed large volume of medical claims on daily basis.
• Used administrative guidelines as resource or to answer questions when processing medical claims.
• Paid or denied medical claims based upon established claims processing criteria.
• Maintain records, files, and documentation as appropriate.
• Meet department production and quality standards. Accurately pulled patient records for upcoming appointments and procedures, typically within 8-hour period.
• Reviewed charts and flagged incomplete or inaccurate information. Communicated effectively with staff, patients and insurance companies by email and telephone.
• Devoted special emphasis to punctuality and worked to maintain outstanding attendance record, consistently arriving to work ready to start immediately.

● Used classification manuals to gain additional knowledge of disease and diagnoses processes.

• Offered advice and assistance to customers, paying attention to special needs or wants.
• Answered constant flow of customer calls with minimal wait times.
• Used company troubleshooting resolution tree to evaluate technical problems and find appropriate solutions.
• Collected customer feedback and made process changes to exceed customer satisfaction goals.
• Maintained customer satisfaction with forward-thinking strategies focused on addressing customer needs and resolving concerns.
• Provided primary customer support to internal and external customers.
• Evaluated account and service histories to identify trends, using data to mitigate future issues.
• Improved overall efficiency by anticipating needs and providing outstanding support