Kamlawattee Rai
Davenport,Florida
Summary
Detail-oriented administrative professional with over 10 years in healthcare operations, specializing in case management tracking and compliance reporting. Demonstrates expertise in managing high-volume workflows, resolving escalations, and ensuring patient access to therapy through effective communication and collaboration.
Overview
1
1
Certification
12
12
years of professional experience
Work History
Patient Experience/ Case manager
Johnson & Johnson
01.2026 - Current
- Answered inbound calls promptly and professionally, serving as main point of contact for patient, provider, and field team inquiries and escalations, achieving one-call resolution.
- Reviewed cases thoroughly and requested necessary documentation from providers and patients to ensure comprehensive case management.
- Verify benefits and determine eligibility for savings program and Patient Assistance for injectable medications.
- Authorized and triaged specialty medications while coordinating shipments, including resolution of lost and damaged medications.
- Meet or exceed KPIs, including call response time, quality scores, and customer satisfaction.
- Handled customer complaints and delivered solutions; escalated complex issues.
- Maintain a thorough understanding of product and service offerings to deliver informed support.
REMS Specialist
Syneos Health
03.2024 - 04.2025
- Processed and validated REMS enrollment and authorization forms to ensure accurate patient, prescriber, and pharmacy alignment in accordance with program requirements.
- Reviewed patient and provider information, laboratory results, and safety documentation to support compliance with REMS protocols.
- Educated patients, healthcare providers, and pharmacies on REMS protocols and safety procedures to enhance program compliance and understanding.
- Collaborated with internal teams, healthcare providers, and pharmacies to resolve REMS-related issues, facilitating timely patient access to therapy.
- Triaged and documented adverse events, updated laboratory results, and escalated safety-related information to ensure compliance with established procedures.
- Conducted timely follow-ups to obtain missing enrollment documentation, laboratory results, patient status forms, and required safety information.
- Performed pre- and post-call reviews to validate ANC laboratory results, patient status forms, and REMS eligibility requirements.
- Provided pharmacy authorization for claim processing and assisted with resolving coverage, authorization, and technical issues.
- Troubleshot IT and technical inquiries, including system access, enrollment processing, documentation, and workflow issues.
Account Representative
Houghton Mifflin Harcourt
09.2019 - 10.2020
- Managed a high-volume portfolio of retail accounts, responding to inquiries regarding product availability, pricing, order status, invoices, and payments.
- Provided phone-based support for order entry, claims, account permissions, invoices, and payment inquiries as key point of contact for Account Executives and retailers.
- Resolved billing issues, order discrepancies, and account-related concerns for Account Executives and retail clients.
- Delivered timely resolutions and proactive support, maintaining strong client relationships throughout order and account management process.
- Supported account management operations by processing retail and supplier orders through SAP, Esker, and Salesforce, ensuring accurate and timely order fulfillment.
- Consistently ranked Top 5 monthly in Quality Assurance (QA) and Net Promoter Score (NPS), demonstrating exceptional customer service, accuracy, and account support performance.
Client Care Representative
Centene Corporation
12.2014 - 04.2017
- Promoted from Customer Service Representative to Service Matter Expert based on strong performance, leadership, and expertise in Pharmacy Benefit Management (PBM) operations.
- Train new employees, support special projects, and resolve escalated member and provider concerns related to pharmacy benefits and coverage.
- Verified pharmacy benefits, ensuring accurate formulary status, copayments, deductibles, coverage limitations, and out-of-pocket costs for members.
- Initiate and track prior authorizations while communicating coverage requirements, documentation needs, and status updates to providers and members.
- Educate members, providers, and internal teams on pharmacy benefit structures, coverage policies, access protocols, and non-clinical benefit navigation.
- Process prescription overrides, early refill requests, lost or stolen medication claims, vacation supply requests, and other pharmacy benefit exceptions.
- Collaborated with Utilization Management and Claims departments to research and resolve discrepancies in pharmacy benefits, eligibility, and claims, enhancing overall member satisfaction.
- Provided technical assistance and subject-matter expertise, facilitating accurate pharmacy claim adjudication and benefit application to streamline payment processing.
Benefits Representative
- Confirmed patient eligibility, plan benefits, coverage limitations, deductibles, copayments, and coinsurance across multiple health plans.
- Verified commercial insurance benefits and coverage using CPT and REV codes to accurately determine patient eligibility and financial responsibility.
- Investigated and resolved claim denials, incorrect rejections, and benefit discrepancies by reviewing payer guidelines and plan requirements.
- Assisted healthcare providers with credentialing and network participation requirements, ensuring compliance and timely resolution of benefit inquiries and contractual issues.
- Supported inquiries on spending accounts and prescription drug coverage, delivering precise benefit information to enhance understanding for providers and patients.
- Initiated and tracked prior authorizations, appeals, and peer-to-peer reviews, effectively communicating requirements and status updates to providers to facilitate timely approvals.
- Documented benefit verification and authorization activities accurately while maintaining compliance with payer and company guidelines.
- Consistently maintained 95%–100% monthly QA scores, demonstrating exceptional accuracy, attention to detail, and quality performance.
Education
Billing and Coding Coursework -
DeVry University
Orlando, FL01-2025
Real Estate License -
IFREC Real Estate School
Orlando, FL01-2020
High School Diploma -
Northeast High School
Fort Lauderdale, FL01-1994
Skills
- Utilization management
- Claims management
- Pharmacy benefits administration
- Patient registration
- Compliance reporting
- EMR / EHR
- Microsoft Office Suite and data entry
- Provider and pharmacy relations
- Patient advocacy
- Case management tracking
- Benefit verification
- Order processing
Certification
- Microsoft Office Specialist (Excel & Word)
- HIPAA Compliance Training
Timeline
Patient Experience/ Case manager
Johnson & Johnson
01.2026 - Current
REMS Specialist
Syneos Health
03.2024 - 04.2025
Account Representative
Houghton Mifflin Harcourt
09.2019 - 10.2020
Client Care Representative
Centene Corporation
12.2014 - 04.2017
Benefits Representative
Billing and Coding Coursework -
DeVry University
Real Estate License -
IFREC Real Estate School
High School Diploma -
Northeast High School