May Rose Clark

- Respond to inquiries from policyholders, potential members and healthcare providers about various aspects of heath insurance policies. This may include explaining coverage details, benefits, premiums, and deductibles.

- Assist policyholders in understanding the claims process, submitting claims, and tracking the status of claims. Also help resolve claims-related issues or dispute.

- Help individuals with enrollment process, verifying eligibility, and guiding them through the necessary paperwork to obtain health insurance.

- Educate Policyholders about the network of healthcare providers and facilities covered by the insurance plan, helping them find In network providers.

- Guide policyholders through the authorization process in care prior authorization is required for specific medical procedures or treatments.

- Address and resolve complaints or concerns from policyholders, ensuring that issues are handled promptly and in accordance with company policies and regulations.

- Maintain accurate records of customer interactions inquiries for reference and compliance purposes.

- Carefully review and assess appeals and grievances submitted by policyholders or their representatives. This involves evaluating the nature of the issue, the applicable policies or regulations.

- Maintain thorough and accurate records of all appeals and grievances, including details of the complaint, supporting documents, dates, and actions taken.

- Conducted investigations into the issues raised in appeals and grievances. This involves gathering additional information or research, call listening, consulting with relevant healthcare providers and assessing the facts and circumstances surrounding the case.

- Acknowledge the receipt of appeals or grievance and provide regular updates on the status of the case.

- Work toward resolving appeals and grievances by collaborating with Clients & internal departments through emails.

- Ensure that the appeals and grievances process complies with all applicable healthcare laws and regulations, including HIPAA and other privacy security requirements.

- Adhere to regulatory deadlines for responding to and resolving appeals and grievances.

- Analyze trends in appeals and grievances to identify areas where process improvements, policy changes, are needed to prevent future issues.

- Provide feedback or coaching to certain CSR based on the information gathered raised by policyholders to address and improve upon the issues that have been reported.

- Educate policyholders or members about the appeals and grievances process, their rights, and how to submit appeals or grievances effectively.

- Ensure all actions takes in appeals and grievances process align with the organization's policies and relevant laws.

- Ensure that appeals and grievances are handled in a timely manner.

- Manage correspondence by carefully reviewing each item and making decisions regarding its routing, including directing it to the appropriate group or determining the necessary actions.

• Engaged with customers to effectively build rapport and lasting relationships.
• Maintained calm demeanor and professionally managed issues in busy, high-stress situations.
• Solved customer challenges by offering relevant products.
• Informed customers of promotions to increase sales productivity and volume.
• Took orders
• Volunteered for extra shifts during holidays and other busy periods to alleviate staffing shortages.

• Assisted team members with tasks, increasing overall efficiency and achieving improved customer satisfaction.
• Operated cash registers and POS systems, handling over $1000 in cash daily.
• Verified freshness of food and ingredients by checking for quality, keeping track of new and expired items and rotating stock.
• Monitored supply inventory and ordered more to maintain smooth and efficient workdays.
• Trained new team members on specific tasks, monitoring work for safety, efficiency and overall progress.
• Cleaned and maintained all areas of restaurant to promote clean image.
• Kept food preparation area, equipment, and utensils clean, organized, and sanitary.
• Prepared products following restaurant, health, and safety standards and procedures.
• Became familiar with products to answer questions and make suggestions.
• Escalated problems or complaints to relevant supervisor or manager for resolution.