Diana Drake

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

years of professional experience

Certification

Work History

Resolution Expert

Expert Global Solutions

09.2020 - Current

Achieve success with a global call center, as a Resolution Expert for a world renown PBM.
Resolve escalated issues by serving as subject matter expert on wide-ranging 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.
Assist caller's with adjusting, correcting and resubmitting claims to achieve a higher success rate of reconciliations,
Conduct thorough investigations into complex claim rejections and complaints, ensuring fair outcomes for all parties involved.
Consistently meet or 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.
Mentor junior team members to always show empathy and compassion with their callers and enhance their knowledge, skills and confidence in conflict resolution and research techniques.
Teach junior team members the proper processes for documenting each call and adding the appropriate Remittance Advice Details (RAD) codes and messages that may be used in reconciling accounts.
Show junior members where to find the appropriate SOP and client benefit pages to better assist the caller and remain compliant with those polices and procedures.
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.
Strive to achieve call handle times of 2 minutes per call
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
Consistently meet or exceed performance metrics related to accuracy, efficiency, and timely resolution of identified threats.
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)

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

05.2019 - 02.2020

Pharmacy Technician

Walgreen's Pharmacy

08.2017 - 05.2019

Education

Diploma -

Norwalk High School

Norwalk, CA

01.1979

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