Detarsha Cole
Mesquite
Summary
Seasoned Provider Relations Representative possessing in-depth knowledge of various insurance plans and policies. Expertise in handling high volume of calls, efficiently resolving disputes and identifying ways to improve processes. Proficient in [Software] and [Software]. Communicative and detail-oriented individual with excellent interpersonal abilities.
Overview
12
12
years of professional experience
Work History
Provider Claim Support
Mphasis Digital Risk
09.2023 - Current
- Meeting individual and team (KPIs)
- Answering calls and emails daily; Handling Medicare/Pace calls in a timely manner
- Complete the volume of work assigned with the ability to organize and prioritize work
- Attends continuing education seminars/training, as requested
- Provide exceptional customer service via phone and email, resolving customer inquiries regarding claims, billing, plan information, account changes, and services.
Medical Claims Specialist
Fourci
05.2018 - 08.2023
- Assist the customer through the Customer Portal to complete the required forms
- Prepare reoccurring and special reports, including simple statistical breakdowns Interview and review documents claimants, police, and other necessary individuals to decide claim denial, settlement, or review
- Verifies insurance eligibility, Medicare Advantage & bennet's via phone, fax, or payer portals
- Provides timely completion of insurance review for established patients
- Documents timely and accurately in the EMR system Reviews payor medical policies to determine medical necessity and/or FDA guidelines including Medicare billing and coding guidelines
- Coordinates with medical providers in obtaining necessary documentation to support medical necessity
- Submits appeal request to payers for denied authorizations and follows-up on timely turnaround.
Escalation/Customer Service Rep
Optum RX
11.2012 - 01.2018
- Identifying, analyzing, and initiating the escalation process in an organization based on the escalation criteria specified by the organization
- Linking the escalation task with incident problem records
- Handling customer complaints Identifying suitable service provider contacts and handing the appropriate customer management services qualified for the task
- Assembling the escalation management team which includes the incident owner, problem owner, and other professionals in the specify area of expertise
- Establishing accurate expectations from the escalating procedures, enforcing relief to the customers and reviewing the situation appraisal formulated by the escalation team for ensuring the consumer satisfaction throughout the escalation process
- Responsible for overseeing the filling of prescriptions, for patient's written by their doctors
- Mailing out those prescriptions, to the patients and providing excellent customer service
Education
High School Diploma -
Cornerstone Christian
07.2005
Skills
HIPAA Compliance
Insurance Regulations Understanding
Healthcare Industry Knowledge
Claims Processing
Timeline
Provider Claim Support
Mphasis Digital Risk
09.2023 - Current
Medical Claims Specialist
Fourci
05.2018 - 08.2023
Escalation/Customer Service Rep
Optum RX
11.2012 - 01.2018
High School Diploma -
Cornerstone Christian
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