Nena Jones

• Respond to and resolve on the first call, customer service inquires and issues by identifying the topic and type of assistance the caller needs such as benefits, eligibility and claims, financial spending accounts and correspondence
• Help guide and educate customers about the fundamentals and benefits of consumer-driven health care topics to include managing their health and well-being by selecting the best benefit plan options, maximizing the value of their health plan benefits and choosing a quality care provider
• Intervene with care providers (doctor's offices) on behalf of the customer to assist with appointment scheduling or connections with internal specialists for assistance when needed
• Assist customers in navigating myuhc.com and other UnitedHealth Group websites and encourage and reassure them to become self-sufficient
• Own problem through to resolution on behalf of the customer in real time or through comprehensive and timely follow-up with the member
• Research complex issues across multiple databases and work with support resources to resolve customer issues and/or partner with others to resolve escalated issues
• Provide education and status on previously submitted pre-authorizations or pre-determination requests
• Meet the performance goals established for the position in the areas of: efficiency, call quality, customer satisfaction, first call resolution and attendance.

• Coordinated with customers to clarify customer needs to submit accurate and comprehensive work request
• Authored and maintained area specific customer service work instructions
• Maintained work request records for aerospace imagery and television services
• Maintained Payload Information Management Systems (PIMS) data for accurate reporting and generated reports
• Maintained Mission Products List (MPL) for each Shuttle Mission and International Space Station flight
• Responsible for metric information and provided metric reports as needed
• Reviewed customer products to ensure request was completed to specifications prior to distribution
• Distributed completed photographic and video products to internal and external customers
• Received photographic and video supplies into inventory
• Maintained office supply inventory.

Responsibilities involved resolving all expedited inpatient hospital, dental, DME and radiology appeals for the Medicare Department (all lines of business)

Prepared appeal packets for each and send to nurse/MD for clinical review

Once review is completed and determination is made, a resolution letter is sent to provider and member.

Adhered to the strict guidelines and time frames set by the Medical Assistance Programs (MAPS), The Center of Medicare and Medicaid Services (CMS), Health Insurance Portability and Accountability Act (HIPAA) and the Health Plan.

Generated and reported documentation supporting verbal and written provider claims and pre-authorization appeals.

2nd level appeals are prepared through Maximums and sent to CMS for 2nd level review.

Worked closely with Provider Relations, Claims, Enrollment and Marketing departments for complaints related to PQ0C and marketing agent issues.

Triaged appeals daily ensuring that all demographic information was correct, then validated appeal into the research work step.