Sr. Service Advocate OPS ~ Health Survey Specialist
Aetna, a CVS Health company
08.2022 - Current
Outreaches to DSNP members via phone to complete the Health Risk Assessment.
Uses motivational interviewing and other consultative techniques to gather comprehensive information about a member’s medical health needs.
Documents each call in the member’s electronic record, thoroughly completing required actions with a high level of detail to ensure we meet our compliance requirements.
Protects the confidentiality of member information and adheres to company policies regarding privacy/ HIPAA.
Demonstrates an outgoing, enthusiastic, and caring presence over the telephone.
Coordinator & Appeal Analyst
Aetna, a CVS Health company
03.2020 - 08.2022
Responded to calls and ensure timely, customer focused response to appeals, and update appeals cases for decisioning.
Reviewed claims for appeals cases using ASD, HRP, GPS and other systems.
Researched and reviewed claims to determine if claim was paid.
Researched claim processing logic to verify accuracy of claim payment, member eligibility data, billing/payment status, prior to initiation of appeal process.
Processed appeals cases for dismissals along with basic experience in Microsoft Applications.
Responsible for coordination of all components of appeals, including final communication to member/provider for final resolution and closure.
Responded to customer inquiries in a call center environment using a computerized system.
Responded to telephone inquiries and complaints using standard scripts and procedures. Gathers information, researched/resolves inquiries, and logged customer calls.
Communicated appropriate options for resolution in a timely manner. Informs customers about services available and assesses customer needs.
Completed pre-hearing conference interviews with appellants who are appealing their eligibility decisions for SNAP, TANF, Medicaid, HIP, & post eligible for ACA.
Researched, analyze, and manage caseloads of cases under appeal to ensure that case information was gathered and processed in a complete and accurate manner in accordance with state policy with quality assurance.
Prepared and presents hearing exhibit packets for fair hearings as a preventative of state of Indiana and run reports daily for task production.
Provided solutions that best meet requirements of hearings & appeals in a performance driven environment using the Workflow Management System WFMS.
Education
Bachelor of Science - Public Affairs, Public Administration
Indiana University Northwest
01.2002
Skills
Excellent verbal and written communication skills
Exhibits heart-at-work behaviors
Meeting all scorecard objectives for a rolling 12 months
Strong analytical and research skills
Typing
Microsoft Office
Microsoft Word
Case Management
Timeline
Sr. Service Advocate OPS ~ Health Survey Specialist
SENIOR MANAGER, NETWORK CONTRACTING at Aetna, a CVS Health Company (First Health Network)SENIOR MANAGER, NETWORK CONTRACTING at Aetna, a CVS Health Company (First Health Network)