Franchesca Sims
Irving,TX
Summary
Hardworking, highly motivated professional eager to lend combined knowledge and skills to enhance business performance. Operates well in both individual and team capacities, leveraging seasoned work ethic to quickly adapt to different processes and drive company objectives. Resourceful and results-driven with a passion for growth and efficiency to meet company needs and increase service value.
Overview
9
9
years of professional experience
1
1
Certification
Work History
Member Service Representative
SCAN Health Plan
06.2024 - Current
- Improved customer satisfaction by providing timely and accurate information on claim status and resolution.
- Maintained up-to-date knowledge of regulatory changes, ensuring company compliance and minimizing legal risks.
- Managed high call volume while maintaining professionalism, empathy, and attention to detail in each interaction.
- Enhanced customer satisfaction by addressing and resolving insurance-related inquiries and concerns.
- Processed insurance policy cancellations and renewals quickly to meet call time targets.
- Fielded customer complaints, escalating complex issues to management for resolution.
- Provided excellent customer service by actively listening to customer concerns and empathetically addressing their needs throughout the appeals process.
- Provided exceptional service through active listening, understanding member needs, and offering appropriate solutions.
- Helped large volume of customers every day with positive attitude and focus on customer satisfaction.
- Reviewed insurance policies to assist customers with benefits questions and coverage
- Assist with premium issues as well as processing of policy payments
PATIENT SUPPORT SPECIALIST
CCS Medical
02.2024 - 05.2024
- Provide exceptional customer service to patients by phone, email, or other communication channels
- Handle inbound and outbound calls from patients regarding product inquiries, order status, and general assistance
- Process orders accurately and efficiently according to claim dates, ensuring the patient receives medical supplies in a timely manner
- Communicate with healthcare professionals, insurance providers, and internal departments to resolve any issues or concerns related to patients medical supplies
- Review physician work orders and HCPC codes to determine if prescribed medical supplies are covered eligible items according to patients insurance provider
- Adhered to all HIPAA regulations when handling sensitive patient information
BUSINESS SUPPORT ASSISTANT
Willis Towers Watson
08.2021 - 02.2024
- Utilize JIRA system software for efficient task distribution across various departments
- Perform quality checks on distributed work to ensure accurate and satisfactory completion
- Generate and deliver requested managerial reports in a timely fashion, adhering strictly to set deadlines
- Initiate outbound calls to participants to assist with transition from employee group coverage to Medicare
- Place conference calls to participants and various insurance provider to resolve application processing issues
- Meet daily production standards while working efficiently to produce quality results
- Provided administrative support to business operations by maintaining detailed records, filing documents, and managing databases
- Performed data entry tasks accurately while meeting established deadlines
MEDICAID ELIGIBILITY SPECIALIST
Kansas Department of Health and Environment
09.2019 - 07.2021
- Conducted thorough evaluations of program benefits and eligibility requirements, providing clear explanations to applicants and clients
- Reviewed and processed applications and re-determinations for Medicaid clients, focusing on Long Term Care, elderly, and disabled individuals, adhering strictly to county, state, and federal policies
- Used the Medicaid Management System (MMIS) to interview clients and review applications for recertification, determining eligibility based on federal poverty level
- Identified discrepancies or inconsistencies in documents submitted by clients and requested additional evidence as needed
- Reviewed Medicaid eligibility applications to determine financial and medical eligibility requirements
- Conducted detailed interviews with applicants to assess their needs and provided assistance in completing application forms
- Developed case files, tracked renewal dates and maintained accurate records of client information
- Processed renewal applications promptly upon receipt in order to prevent lapse in coverage for existing beneficiaries
- Maintained up-to-date knowledge of changing federal and state regulations governing Medicaid programs
- Verified income levels, assets and other pertinent information from a variety of sources including tax returns, pay stubs, bank statements and Social Security documents
MEDICAID ELIGIBILITY SPECIALIST (CONTRACTOR)
Maximus
03.2018 - 06.2019
- Conducted thorough evaluations of program benefits and eligibility requirements, providing clear explanations to applicants and clients
- Scrutinized applications for initial eligibility and re-certification, ensuring adherence to relevant county, state, and federal policies, statutes, and guidelines
- Assessed applications and re-determinations for specific demographics (Long Term Care, elderly, disabled) using the Medicaid Management system (MMIS), and determined client's eligibility for Medicaid health plans based on federal poverty levels
- Identified discrepancies or inconsistencies in documents submitted by clients and requested additional evidence as needed
- Conducted detailed interviews with applicants to assess their needs and provided assistance in completing application forms
- Developed case files, tracked renewal dates and maintained accurate records of client information
- Researched benefits available through other agencies for individuals who are not eligible for Medicaid services
- Communicated effectively with clients via phone calls, emails or face-to-face meetings to explain program requirements and answer questions
TOLL ENFORCEMENT SPECIALIST
Faneuil
01.2016 - 02.2018
- Answer inbound calls from North Dallas Tollway Customers
- Conducted comprehensive customer account analysis, effectively resolving various issues
- Managed customer communications to identify overdue payments, address concerns, establish payment arrangements, and process transactions
- Maintained meticulous records of collection activities and generated detailed reports
- Trained personnel on relevant enforcement procedures and protocols
- Developed strong problem solving and decision-making skills while enforcing regulations in a fast-paced environment
Education
GED -
Macarthur High School
Irving, TX01.2001
Skills
- Microsoft Word
- Windows 10
- 10 Key Alpha Numeric
- Customer service
- Windows
- MedHok
- Jira
- Organizational skills
- Microsoft Excel
Certification
- First Aid Certification
- CPR Certification
- Driver's License
References
References available upon request
Timeline
Member Service Representative
SCAN Health Plan
06.2024 - Current
PATIENT SUPPORT SPECIALIST
CCS Medical
02.2024 - 05.2024
BUSINESS SUPPORT ASSISTANT
Willis Towers Watson
08.2021 - 02.2024
MEDICAID ELIGIBILITY SPECIALIST
Kansas Department of Health and Environment
09.2019 - 07.2021
MEDICAID ELIGIBILITY SPECIALIST (CONTRACTOR)
Maximus
03.2018 - 06.2019
TOLL ENFORCEMENT SPECIALIST
Faneuil
01.2016 - 02.2018
GED -
Macarthur High School
- First Aid Certification
- CPR Certification
- Driver's License
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