Summary
Overview
Work History
Education
Skills
Personal Information
Accomplishments
Timeline
Generic

Cassandra Mccullar

Irving,TX

Summary

Adept at navigating complex Medicare claims and enhancing customer experiences, I leveraged my problem-solving aptitude and Microsoft Windows expertise at United Healthcare to streamline processes. Recognized for exceptional customer service, I efficiently managed a diverse caseload, significantly improving client satisfaction and operational efficiency.

Overview

9
9
years of professional experience

Work History

Claims Customer Care Representative

CVS Pharmacy
Dallas, TX
08.2024 - Current
  • Answered incoming calls and emails, providing frontline customer support or assistance with product and service transactions.
  • Engaged in conversation with customers to understand needs, resolve issues and answer product questions.
  • Advised customers on available coverage options that best fit their individual needs.
  • Utilized CRM software to document customer interactions, feedback, and resolutions.
  • Assisted customers with filing and tracking of insurance claims, ensuring timely resolution.
  • Retained strong medical terminology understanding in effort to better comprehend procedures.

HR Project Manager (Temp)

Varsity Brands Inc
Farmers Branch, TX
05.2023 - 09.2023
  • Lead the planning, execution, and delivery of HR improvement projects aimed at enhancing the HR function
  • Define project scope, objectives, deliverables, and timelines in alignment with organizational goals
  • Partner with HR leadership and team members to ensure accountability for meeting project timelines and objectives
  • Maintain thorough project documentation, including project plans, schedules, and status reports to track progress and identify potential issues
  • Prepare and deliver reports on project progress, outcomes, and lessons learned to stakeholders for informed decision-making

HR Specialist-Disability and Leave services

Amazon
Dallas, TX
06.2022 - 02.2023
  • Served as a primary point of contact for 150-200 employees, providing comprehensive case management services related to short-term and long-term leave and disability events
  • Initiated and responded to inquiries about leave and disability benefits, effectively communicating available options to employees
  • Reviewed medical documentation to adjudicate leaves in compliance with corresponding leave plans, federal and state laws, and Amazon benefit plans
  • Utilized duration guidelines, best practice tools, and Amazon resources to oversee leave events
  • Adapted case management plans to accommodate employees' changing needs and address sensitive situations
  • Proactively identified and resolved problems and barriers related to leave events, often with limited information
  • Facilitated a smooth return-to-work and ramp-back plan for employees returning to the workplace
  • Educated managers and business partners on employee concerns and needs before, during, or after leave events
  • Communicated regular updates to employees and stakeholders through verbal and written channels
  • Ensured compliance with standard work, federal/state regulations, and company policies
  • Maintained accurate and timely system records to support documentation and reporting requirements
  • Collaborated and coordinated with third-party administrators, HR, Safety, Legal, Payroll, Benefits, and other departments/systems as needed to deliver optimal solutions

Disability Claims Examiner

Sedgwick
California
06.2021 - 02.2022
  • Manages assigned caseload of short-term disability (STD) and long-term disability (LTD) and/or Family & Medical Leave Act (FMLA) claims
  • Determines whether to return, pend, deny or pay claims
  • Inputs data
  • Evaluates claimant eligibility via information received from claimant, attending physician, and employer
  • Decides payment period, follows up and monitors payment accuracy and timeliness
  • Follows established claim policies and practices to resolve claims and issues
  • Performs other related duties as assigned or required
  • Manage, reconcile and submit payment in a timely manner for all benefits related invoices, such as medical, dental, vision, transit, FSA, COBRA etc
  • Maintain all statistical data relative to claims, cost, and premiums
  • Responsible for maintaining employee benefits, benefits filing systems and ensure benefits changes are entered appropriately in payroll system for payroll deduction and payroll auditing as it relates to benefits
  • Administer all LOA (STD/LTD/NYPFL/FMLA) along with workers compensation

Senior Medical Claims Specialist

Christus Health
06.2019 - 06.2020
  • Accurately evaluates and adjudicates complex Medicare part A,B, and D(prescription) claims in a timely manner and according to set standards
  • Complex claims include but not limited to UB facility claims
  • Ensure compliance with member benefit regulations across all product lines (Essential Health Benefits, State Provider agreements, CMS requirements, Mental Health Parity, etc.)
  • Process Medicaid (Medi-Cal) grievances and appeals, Medicare grievances and appeals
  • Assists in optimizing work flows, troubleshooting and problem solving to claims
  • Examine institutional claims and calculate reimbursement based on contract terms to determine accuracy of payment through use of various reports and supporting documentation
  • Establishes FMLA claims; tracks and codes documentation in accordance with internal workflow processes
  • Facilitate escalated communication between stakeholders, employees with disabilities, as well as leave of absence, STD, LTD, and workers compensation

Medicare Claims Specialist

United Healthcare
06.2016 - 01.2018
  • Process 30-60 Medicare part A, B and D medical claims according to health plan policies, using icd 10 codes, cpt codes
  • Process Medicaid (Medi-Cal) grievances and appeals, Medicare grievances and appeals
  • Respond to and own consumer inquiries and issues by identifying the topic and type of assistance the caller needs such as benefits, eligibility, claims, financial spending accounts, correspondence, OptumRx Pharmacy, Optum Behavioral Health and self-service options
  • Educate members about the fundamentals and benefits of consumer-driven health care topics to include managing their health and well-being so they can select the best benefit plan options and maximize the value of their health plan benefits
  • Advocate and intervene with care providers (doctor's offices) on behalf of the member to assist with appointment scheduling, billing concerns, and coverage determinations
  • Assist members in navigating uhc.com and other UnitedHealth Group websites or applications utilizing remote desktop system capabilities
  • Answer up to 30 to 60 incoming calls per day from members of our health / dental / vision / pharmacy plans
  • Performs claims adjustments/dollar payments to providers and/or members ultimately impacting UHC costs or commercial account costs
  • Interpret and translate clinical / medical terminology into simple-to-understand terms for members
  • Respond to and resolve on the first call, member service inquiries and issues by identifying the topic and type of assistance the caller needs, such as; benefits, eligibility and claims, financial spending accounts and correspondence
  • Navigate through multiple platforms and databases to retrieve information regarding medical plans, prescription plans, flexible spending accounts, health reimbursement accounts, vision plans, dental plans, employer-based reward plans, claims submissions, clinical programs, etc
  • Educate members about the fundamentals of health care benefits including: Managing health and well-being programs
  • Investigate claims, and provide telephone coverage for customer service department
  • Process payments via telephone regarding Medicare insurance premiums
  • Review and respond to complaints, grievances and appeals within the stated time frame for each request
  • Ensure compliance with established icd-10, icd-9, CM coding guidelines, third party reimbursement policies, regulations and accreditation guidelines

Education

Master's degree - Psychology

Walden University
Minneapolis, MN
11.2019

Skills

  • Customer service
  • Medicare
  • EMR systems
  • Medical scheduling
  • Insurance verification
  • Medical records
  • FMLA
  • ADP
  • Problem-solving aptitude
  • Microsoft windows expert

Personal Information

Willing To Relocate: Anywhere

Accomplishments

  • National Society of Leadership and Success

Timeline

Claims Customer Care Representative

CVS Pharmacy
08.2024 - Current

HR Project Manager (Temp)

Varsity Brands Inc
05.2023 - 09.2023

HR Specialist-Disability and Leave services

Amazon
06.2022 - 02.2023

Disability Claims Examiner

Sedgwick
06.2021 - 02.2022

Senior Medical Claims Specialist

Christus Health
06.2019 - 06.2020

Medicare Claims Specialist

United Healthcare
06.2016 - 01.2018

Master's degree - Psychology

Walden University

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Cassandra Mccullar