Microsoft Outlook
Diana Drake
Customer Service Resolution Expert
North Las Vegas,NV
Summary
Experienced Resolution Expert specializing in claim resolution, problem-solving, mediation, negotiation, communication, and fraud detection. Known for empathy, compassion and adaptability toward a proactive approach in delivering effective solutions for clients, pharmacies, and patients. Skilled at fostering partnerships and collaboration across teams. Results-oriented achiever consistently exceeding targets in fast-paced environments. Maintains 100% Quality Assurance scores from Client, Operational, and Team Managers. Combines strategic thinking with practical experience to enhance organizational performance. Offers a fresh perspective and unwavering commitment to quality and success.
Overview
8
8
years of professional experience
1
1
Certification
Work History
Resolution Expert
Alorica Expert Global Solutions
Work At Home
09.2020 - Current
- Achieve success with a Alorica global call center, as a Resolution Expert for Express Scripts.
- Resolve escalated issues by serving as subject matter expert on wide-ranging pharmacy services issues.
- Receive over 100 escalated inbound calls a day from pharmacies, doctor's offices, benefit organizations and pharmacy help desk agents, to audit pharmacy claims.
- Utilize in-depth professional knowledge and acumen to quickly resolve any issues or transfer the caller to another department when necessary.
- Protect patient's and members PHI and stay compliant with HIPAA regulations.
- Access member's plan information and assist caller's with adjusting, correcting and resubmitting claims to achieve a higher success rate of reconciliations,
- Refer to plan benefit pages and enter claim reversals, overrides and prior authorizations as each benefit will allow.
- Conduct thorough investigations into complex claim rejections and complaints, ensuring fair outcomes for all parties involved.
- Consistently exceed performance metrics related to accuracy, efficiency, and timely resolution of pharmacy claims.
- Perform data analysis, investigation, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse for the Centers of Medicaid and Medicare.
- Train colleagues on best practices for handling difficult conversations, resulting in improved team performance during challenging interactions.
- Contribute significantly towards building a positive work culture focused on teamwork, integrity, and continuous improvement initiatives.
- Provide exceptional support during high-pressure situations, diffusing tension and facilitating productive discussions towards resolutions.
- Collaborate with cross-functional teams to develop strategies for improving overall service quality.
- Utilize analytical skills to identify patterns in customer complaints, recommending targeted improvements to address underlying issues systematically.
- Develop strong relationships with clients, leading to higher levels of trust and more effective problem-solving efforts.
- Enhance customer trust by promptly addressing Medicare, Medicaid and plan benefit fraud and communicating the results of investigations.
- Analyze transaction data to identify potential fraudulent activities, protecting company assets and misrepresentation of the member's benefit plan policies and procedures
- Master all understanding of and remain up to date and compliant with all assignments in the Learning Management System.
Pharmacy Help Desk Agent
Expert Global Solutions (now Alorica)
Hybrid/Remote
02.2020 - 09.2020
- The primary purpose of this position is to engage in and maintain regular communication with physicians, benefit office staff, pharmacy personnel, client managed prior authorization staff, and specialty pharmacies., to support, document, and coordinate patient hub services.
- Handled over 50 incoming calls per day
- Assist pharmacies in reprocessing and investigating rejected claims for medications for pharmacy patients.
- Manage and maintain patient pharmacy claim records, adhering to HIPAA guidelines and ensuring confidentiality and accuracy.
- Skilled at working independently and collaboratively in a team environment.
- Proven ability to learn quickly and adapt to new situations.
- Learned and adapted quickly to new technology and software applications.
- Developed and maintained courteous and effective working relationships.
- Collaborated with healthcare providers to resolve medication discrepancies, resulting in improved patient care.
- Managed a high volume of inbound calls while maintaining composure under pressure and delivering excellent service.
- Demonstrated empathy and professionalism while handling sensitive patient information and concerns.
- Contributed to the team''s success by meeting call center performance metrics consistently.
- Reduced call wait times by efficiently triaging incoming calls, streamlining communication between pharmacy staff and patients.
- Supported quality assurance initiatives by adhering to company policies and procedures throughout all interactions.
- Improved customer satisfaction by addressing and resolving complex pharmacy-related inquiries.
- Provided exceptional support to patients navigating insurance issues, facilitating timely access to medications.
- Exceeded personal goals related to productivity, adherence, quality scores, and overall performance evaluations.
- Participated in ongoing training programs to stay current on industry trends, regulations, and company updates.
- Investigated and resolved customer inquiries and complaints quickly.
- Responded to customer requests, offering excellent support and tailored recommendations to address needs..
- Responded proactively and positively to rapid change.
- Promoted superior experience by addressing customer concerns, demonstrating empathy, and resolving problems swiftly.
- Utilized various software applications proficiently for efficient case management and documentation purposes.
Customer Service Representative
Alorica
Las Vegas, NV
05.2019 - 02.2020
Pharmacy Technician
Walgreen's Pharmacy
08.2017 - 05.2019
Education
Diploma -
Norwalk High School
Norwalk, CA01.1979
Skills
- Quantitative research
- Analytical skills
- HIPAA Regulations
- Centers for Medicare/Medicaid
- Claim Investigation
- Fraud identification
- Confidentiality
- Critical Thinking
- Microsoft Office/Teams/Windows apps
- Customer Relationship Management (CRM)
- Data analysis
- Claims Processing
Affiliations
- National Association of Professional Women
Work Availability
monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Software
Microsoft Teams
CX custom software
WebEx
Microsoft Excel
Timeline
Resolution Expert
Alorica Expert Global Solutions
09.2020 - Current
Pharmacy Help Desk Agent
Expert Global Solutions (now Alorica)
02.2020 - 09.2020
Customer Service Representative
Alorica
05.2019 - 02.2020
Pharmacy Technician
Walgreen's Pharmacy
08.2017 - 05.2019
Diploma -
Norwalk High School
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