MYCARLIE LAVENTURE

• Delivered excellent customer service by handling high-volume inbound and outbound calls, identifying call intent, and resolving member concerns efficiently.
• Assisted members with eligibility, benefits, plan coverage, and Medicaid-related support, ensuring accurate and informative communication.
• Assisted with medical record requests by verifying member information, documenting requests, and routing information through the proper process in compliance with HIPAA.
• Educated members on extra/additional benefits offered through their health plan and provided guidance on how to access available services.
• Submitted and processed requests for additional benefits/services, ensuring proper documentation and correct routing for completion.
• Supported members with prior authorizations and referrals, including checking status, explaining requirements, and guiding members on next steps for approval.
• Reviewed medical claim history, including claims for procedures and services, and provided clear claim status updates and explanations.
• Assisted members with transportation benefit inquiries by verifying coverage and transferring members to the appropriate transportation department/vendor.
• Conducted outbound pharmacy outreach to help members access medications and resolve urgent prescription barriers.
• Investigated and corrected Coordination of Benefits (COB) issues that prevented pharmacy claims from processing and delayed medication pick-up.
• Reviewed and explained pharmacy benefits and pharmacy claim status, helping members resolve coverage issues and successfully pick up prescriptions.
• Processed appeals and grievances, ensuring accurate documentation and proper escalation in accordance with policy.
• Responded to billing and payment inquiries, providing professional guidance and solutions.
• Completed accurate case documentation (CSP), case transfers, and scheduled follow-up activities to support end-to-end issue resolution.
• Maintained strict HIPAA compliance, confidentiality, and professionalism while meeting productivity and performance expectations.

• Assigned case managers to members and actively coordinated outreach via Microsoft Teams to ensure timely communication, continuity of care, and case resolution

• Coordinated new patient intake by collecting required demographics, health information, and service details for home health support.
• Verified and updated patient information, ensuring accurate documentation and complete intake records.
• Processed and tracked referrals and intake requests, ensuring timely review and proper routing to the appropriate team.
• Served as a main point of contact for patients and families by handling inbound/outbound calls and providing clear updates.
• Communicated with internal departments to ensure a smooth start-of-care coordination and service coverage.
• Maintained patient confidentiality and complied with HIPAA and company policies while handling sensitive information.
• Assisted with scheduling coordination by confirming details and supporting intake workflow to prevent delays in care.
• Documented all interactions and updates in internal systems to support accurate case management and follow-up.
• Addressed patient concerns professionally and escalated issues appropriately to support quality care.
• Met productivity and quality standards in a fast-paced healthcare environment.