Kivalina Grande
Beavercreek,OH
Summary
Experienced professional seeking position using applied comprehensive understanding of healthcare practices to provide exceptional support and assistance to patients and medical staff.
Overview
8
8
years of professional experience
Work History
Client Advisor
RetireMedIQ
08.2022 - 12.2022
- Assisted clients in transitioning from Medicare supplement plans to Advantage plans. Provided detailed information regarding benefits and costs. Conducted cost/benefit analyses to identify optimal plans for clients. Managed Part D medications and assessed Low-Income Subsidy eligibility. Researched drug options based on each insurance plan's Medicare Part D and communicated lowest costs to clients. Consulted PBM formulary for coverage alternatives. Adhered to all CMC guidelines. Maintained organized workspace, files, and appointment preparations. Documented interactions accurately and followed up with clients as needed.
Claims Representative
Heartland health and wellness
02.2022 - 04.2022
- Assisted union members in filing claims with third-party insurance company. Supported new members by addressing inquiries and providing guidance. Utilized various software tools to streamline processes and enhance member assistance.
Member Advocate
Humana - Work at Home
10.2021 - 02.2022
- Achieved high levels of member satisfaction by effectively managing inbound calls from Medicare members. Resolved member issues through thorough investigation and resource utilization, demonstrating strong customer service skills. Maintained accurate documentation across multiple systems, ensuring seamless service delivery. Provided detailed pricing information based on CPT codes and processed Medicare Part D pharmacy claims efficiently. Initiated prior authorizations when necessary and confirmed coverage options through the plan formulary. Followed all CMC guidelines to uphold service standards.
Claims Specialist
Dayton Gastroenterology
04.2021 - 09.2021
- Achieved accurate claims processing through diligent examination and proper insurance attachment. Enhanced eligibility research efforts on Medicare.gov and Medicaid, aligning with CMC guidelines. Streamlined delinquent account management and validated claims coding with precise ICD-10 classifications.
CSR - Customer Service Representative
CareSource
08.2020 - 04.2021
- Provided exceptional customer support by addressing questions related to medical plan benefits, pharmacy benefits, and DME benefits. Documented customer complaints for future reference. Handled emails and calls efficiently while working remotely. Supervised customer account management. Evaluated claims and physician-related services. Initiated prior authorizations for medications and coordinated follow-ups for status updates. Partnered with in-house PBM and retail pharmacies to enhance medication management processes.
Relevant Employment: inventory management
Meijer Pharmacy
04.2015 - 10.2015
- Achieved high levels of customer satisfaction through effective prescription processing and resolution of insurance challenges. Enhanced operational efficiency by managing inventory and organizing medication records. Proactively sourced medications from network stores to meet patient needs promptly.
Education
Associate of Science - Chemistry
04.2015
Certificate - Phlebotomy
04.2011
Certificate - Pharmacy Technician
05.2010
Skills
- Communicate clearly and concisely
- Self motivated
- Enjoy working in a very orderly and concise fashion
- Enjoy patient/customer interaction and working in a team as well as independently
- Skilled with using various computer programs
- HIPAA compliance
- Insurance verification
- Medical terminology
- Call center experience
- Claims processing
- EHR management
- Patient payment processing
- Record maintenance
- Strong interpersonal skills
- Multitasking and organization
- Problem-solving
- Phone and email etiquette
- Conflict resolution
- Calm and professional under pressure
- De-escalation techniques
- Call documentation
- Call metrics
- Remote office availability
Personal Information
Work Permit: Authorized to work in the US for any employer
Timeline
Client Advisor - RetireMedIQ
08.2022 - 12.2022
Claims Representative - Heartland health and wellness
02.2022 - 04.2022
Member Advocate - Humana - Work at Home
10.2021 - 02.2022
Claims Specialist - Dayton Gastroenterology
04.2021 - 09.2021
CSR - Customer Service Representative - CareSource
08.2020 - 04.2021
Relevant Employment: inventory management - Meijer Pharmacy
04.2015 - 10.2015
Sinclair Community College - Certificate, Pharmacy Technician
Sinclair Community College - Associate of Science, Chemistry
Sinclair Community College - Certificate, Phlebotomy