Brittany Members
Florida
Summary
Detail-oriented and highly organized with over 7 years of experience in customer service and Health care management. I offer great people skills, organized file management, administration and deep understanding of Provider, Patient and Health Plan needs.
Overview
8
8
years of professional experience
Work History
Credentialing Specialist
Sunshine Health Plan
Plantation, FL
07.2022 - Current
- Review and process credentialing applications to ensure accuracy, completeness, and compliance with all NCQA accreditation standards.
- Work in both Xcelys and Amisys to verify and update provider data
- Communicate with with office managers, providers, and other third parties to secure needed information.
- Maintained informational resources, tracking and documenting requests for updates, certification and credentialing.
- Check emails in an timely manner to make sure all documents is processed on time to meet company standards and are in compliance with claims.
Referral Specialist II
Sunshine State Health Plan
Plantation, FL
02.2020 - 07.2022
- Assist with creating Authorizations for all service types including Outpatient, Inpatient, Rehab, Hospice, Home Meals/ Post Discharges, Transportations and Peer-to-Peer (P2P) Cases working with Medical Directors .
- Respond to escalated emails resolving any claim issue for providers by researching auth errors to ensure contractual compliance with turn around times, correct billing and and patient care.
- Provide Training for new and current Referral Specialist.
- Identify with all CPT/ Procedure Codes and Insurance verification including Medicare, AmBetter, Medicaid, and Third Party insurance redirecting or giving the member the appropriate care due to coverage, eligibility and proficient in Medical Terminology.
- Document and track Approved, Pending, or Voided Authorizations through Excel.
- Process Referrals and research claims inquiry specific to the department and responsibility .
- Assist with redirecting request to the correct departments including DME/HH, Pharmacy, Long Term Care, and Behavioral Health by identifying the patient care and assessments.
Referral Specialist I
Sunshine State Health Plan
Plantation, FL
06.2018 - 02.2020
- Answer phone queues and process faxes within established assisting providers with any questions or concerns about processing or checking status on Authorizations.
- Verify eligibility, benefits, Document calls and notate members accounts .
- Initiate authorizations request for Outpatient and Inpatient services within Turn around time.
- Delivered fast, friendly and knowledgeable service for routine questions and service complaints.
- Documented customer correspondence in CRM to track requests, problems and solutions.
- Collaborated with other departments to ensure that all aspects of patient care are addressed and referrals are processed for providers.
- Communicated effectively with physicians and other healthcare professionals.
Customer Service Representative
A1 Diabetes & Medical Supply
Deerfield Beach, FL
12.2015 - 05.2018
- Provide information about Durable Medical Equipment and services
- Assist with enrollment for members who qualify for Pill Pack Pharmacy.
- Verify patient information and activated customer accounts.
- Promoted high customer satisfaction by resolving problems with knowledgeable and friendly service.
- Made outbound calls to obtain account information and customer payments.
- Mentored and Train new employees on procedures and policies to maximize team performance.
Education
High School Diploma -
Penn Foster Career School
Scranton, PA2012
Skills
- Time Management
- Problem- Solving
- Communication
- Customer service
- Office Administration
- Medical Terminology
Timeline
Credentialing Specialist
Sunshine Health Plan
07.2022 - Current
Referral Specialist II
Sunshine State Health Plan
02.2020 - 07.2022
Referral Specialist I
Sunshine State Health Plan
06.2018 - 02.2020
Customer Service Representative
A1 Diabetes & Medical Supply
12.2015 - 05.2018
High School Diploma -
Penn Foster Career School
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