MICHELLE M. GRIFFITH

• Escalate submission issues and working multiple issues concurrently to stay within compliance TAT
• Escalate large terminations not submitted by UHN to Local Markets for validation
• Handled large scale term requests with thousands of members. Verified term and notified members
• Picked to be on auditing team to do peer audits to ensure that we are notifying members and uphold contractual obligations
• Assist delegates with issues resolution and communicating with senior leadership when necessary
• Research and resolve or advise on capitation issues, TIN trends, or provider eligibility issues
• Assisted with training of new team members and uptraining and auditing member notification team on different LOBS
• Always looking for new ways to improve our overall process and communicate with the team
• Assisting with other teams under this dept to help drive workload down and stay in compliance and always willing to work OT to assist with keeping our workload within compliance time frames.

• Assisted with COVID Isolation and COVID-19 Food Insecurity and Emergency Preparedness Outbound Call Campaign
• Handled DSNP and Medicaid members for multiple states, and responded and researched customer inquiries and resolutions
• Compliance pre-checker for all DSNP reps from Pittsburgh site
• Consulted with the resolution analyst team
• Set, prioritize, and completed commitments and projects set by me and given by upper management
• Presented and uptrained team members, acted as point of contact and team lead

· Assisted patients with all aspects of insurance benefits (pharmacy vision, behavioral health, medical) and documented any information or conversations in the computer regarding the patient's accounts.

· Resolved problems and escalated to SME and supervisor as needed -able to diffuse intense situations and frustrated callers.

· Utilized knowledge of the healthcare insurance field by explaining insurance coverage benefits and medical care cost to patients.

• Used Rally to assist members with finding solutions and assistance outside of company (IE housing, food assistance, pest control, etc)

· Responsible for verifying patient eligibility, coordinating benefits, running test claims and determining patient coverage/responsibility for services including, but not limited to primarily major medical insurance benefits verification, complex insurance plan verification and high volume PBM plans.

· Verifies patient insurance coverage of medications, administration supplies and related pharmacy services through proper investigation into either major medical benefits (including Medicare) or pharmacy benefits.

· Facilitates and completes the prior authorization process with insurance companies and practitioner offices.