Summary
Overview
Work History
Education
Skills
References
Certification
Skillsinterestsawards
Timeline
Generic
Pamela S. Jeffers

Pamela S. Jeffers

Lawrenceville,GA

Summary

I am a top performer, award winning for performance and contest winner at work achievements. I am seeking a career as a Administration Medical Support (Advanced)

Overview

33
33
years of professional experience
1
1
Certification

Work History

Senior Pharmacy Resolution Specialist

Centene Corporation
01.2023 - Current
  • Acts as a subject matter expert and handles more complex pharmacy issues and responds to escalated calls from members, provider/physician's offices and pharmacies
  • Makes outbound calls and enters pharmacy overrides into systems based on approved guidelines and approvals provided from clinical pharmacists
  • Takes member/prescriber/pharmacist inquiry calls for benefit questions including prior authorization requests
  • Offers options including submission of a prior authorization request
  • Thoroughly researches issues and takes appropriate action to resolve them using the appropriate reference material within turnaround time requirements and quality standards
  • Answers and conducts inbound and outbound calls with members and provider offices to provide resolution to claims (i.e.: additional information requests and medication determination updates)
  • Thoroughly researches issues and takes appropriate action to resolve them within turnaround time requirements and quality standards
  • Assists team members often guiding them to the appropriate resolution of more complex and difficult inquiries
  • Participates in the training of less experienced staff, including opportunity for job shadowing
  • Acts as a liaison between internal departments on data gathering and problem solving while investigating problems of an unusual nature in the area of responsibility
  • Presents proposed solutions in a clear and concise manner
  • Obtaining medical information from patients, documenting this information accurately in the appropriate system and communication accurately and timely to the appropriate clinician, pharmacy representative or team as needed
  • Interacting with internal and external customers to achieve desired outcomes
  • Verifying and updating demographics for every call received
  • Prioritizing calls and making decisions based on caller needs
  • Completing any additional duties or task that may be assigned by the supervisor to ensure efficient daily operations, during hours of low call volume, to assist other sections within the Medical Facility to meet their goals
  • Supports patient safety standards using the correct Medical identification of all patients through the use of two forms of identification, name and full Social Security Number
  • He/she must use each interaction with the patient to validate and update patient demographic information, either in person during check-in or over the phone, to decrease the incidence of returned mail due to incorrect addresses and inability to contact patients by phone due to incorrect numbers
  • As front-line contact with patients and staff, the incumbent sets the tone for perception concerning quality of healthcare services
  • A high degree of tact and diplomacy is required when dealing with patients who have multiple health problems and who may be frustrated with the administrative process associated with diagnosis and treatment
  • A caring, compassionate and sensitive manner is essential when explaining procedures to patients and their family members both in person and on the phone
  • Must screen/receive phone calls in a courteous and timely manner, determine the nature of requests and provide the information desired using privacy rules and established clinic processes
  • Additional duties or tasks may be assigned by the supervisor to ensure efficient daily operations
  • Must be able to interpret and communicate requirements of patient Scheduling Directives and complete accurate scheduling responsibilities and assist in training SMCE

Senior Eligibility and Prescription Claims Account Mgr.

Cigna
01.2022 - 01.2023
  • Company Overview: Express Scripts/Accredo
  • Benefits Verification and Prescription Claims Specialist contacts insurance companies, on behalf of the physician's office, to verify patient specific benefits
  • The Benefits Verification Specialist will ask appropriate questions regarding patient's benefits and complete data entry and/or appropriate forms to document patient's benefits coverage
  • Responsibilities: Collects and reviews all patient insurance information needed to complete the benefit verification process for multiple entities
  • Verifies patient specific benefits and precisely documents specifics for various payer plans including patient coverage, cost share, and access/provider options according to Program specific SOPs
  • Verification process could include electronic validation of pharmacy coverage and medical eligibility
  • Identifies any restrictions and details on how to expedite patient access
  • Could include documenting and initiating prior authorization process, claims appeals, etc
  • Completes quality review of work as part of finalizing product
  • Reports any reimbursement trends/delays to supervisor
  • Performs related duties and special projects as assigned
  • Ability to work in a fast-paced office environment
  • Contributes to the team effort by completing other tasks/projects as needed
  • Community Care referrals
  • Serves as the initial point of contact for units, clinics, patients, call centers, Care in the Community regarding various aspects of patient appointments and referrals
  • Express Scripts/Accredo

Senior Health Advocate4me E&I

United Healthcare
01.2021 - 01.2022
  • Respond to and resolve, on the first call, customer service inquiries and issues by identifying the topic and type of assistance the caller needs such as benefits, eligibility and claims explanations and reprocessing, financial spending accounts and correspondence
  • Help guide and educate customers about fundamentals and benefits of consumer-driven health care topics to select the best benefits plan
  • Maximize the value of their health plan benefits and choose a quality care provider
  • Call Providers and assist on navigating Myuhc.com and other Unitedhealth Group websites
  • Worked on Special Projects and overflow with the Quality Assurance team for new hire training
  • Testing new programs for management, monitor and inspect the quality of the systems
  • Assist QA team with SOP's and training in Learn Source, developing courses and policies and procedures
  • Performed other various duties as assigned

Financial Services, Advisor

Northwell Health
01.2019 - 01.2021
  • Primarily performing all functions within a customer teleservicing center, servicing a high volume of billing related customer requests
  • Understand the intricacies of health care billing and strong knowledge of medical terminology to communicate effectively
  • Have financial conversations and drive the collection of payments
  • Promote meaningful and positive payment experiences through relevant and informed conversations with customers regarding the financial services that we can offer
  • Create flawless experiences for our customers by addressing customer inquiries and resolving service and medical insurance issues that include but are not limited to: researching and analyzing accounts receivable and outstanding balances, negotiating and advising on the collection of overdue bills and payment plans, collecting overdue payments, understanding financial assistance offerings, managing and resolving customer disputes
  • Address and resolve complex escalated billing and service issues utilizing department policies and procedure manuals, guidelines and other reference materials
  • Create innovative ways to resolve customers' issues or concerns to win their loyalty
  • Provide input for new service processes and strategies
  • Be accountable and take ownership of the customer's experience from beginning to end
  • Identify opportunities to proactively meet member needs to deliver value added recommendations and services
  • Meet individual performance objectives based on customer satisfaction, productivity and overall positive/proactive behavior, while participating in training sessions to remain current on various policies, processes, systems and procedures related to servicing of customers
  • Registers/re-registers patients
  • Reviews registration forms for completeness and accuracy of data and performs data entry
  • Updates insurance information obtained by Hospital registrars
  • Verifies insurance coverage for elective surgeries, high dollar services, and patients with ongoing courses of treatment
  • Notifies patients and arranges for alternative payment methods when insurance coverage does not cover services/courses of treatment
  • Collects point of service payments, as appropriate
  • Arranges budget plans in accordance to income
  • Prepares payment transmittals for point of service and mail payments, as received
  • Answers on-site patient inquiries regarding account or payment status for all practices at the hospital
  • Answers patient and insurance inquiries in regards to medical accounts
  • Performs verification of insurance found on HDX
  • Performs related duties, as required
  • Work with internal departments to achieve common goals
  • Insurance verification
  • Working with Artiva, HDX, IDX, Keane, Sorian, Franklin, LIJ and PAANS systems

Customer Service Representative (CSR) -Router -Mass Transit Specialist

Logisticare, LLC
01.2017 - 01.2019
  • CSR-Transportation and integrated Health Services and insurance
  • Interact with customers to provide information in response to inquiries about products and services pertaining to Medicaid and to handle and resolve complaints
  • Also ensure the efficient and accurate entering of all requests into LogistiCare's system as well as documenting complaints and issues while providing superior customer service to enrollees
  • Dispatcher/Router - I primarily am responsible for routing trips to transportation providers by performing the following duties: Reviewing the regional trip reservations utilizing the proprietary software, LCAD
  • Assigning reservations to network transportation providers to ensure that vehicle resources are used most efficiently and effectively to meet client demand
  • Perform other duties as assigned
  • Strong Customer Service skills
  • Mass Transit Specialist Identifies potential Medicaid recipients/ clients that meet the criteria for using the Public Transit system and Gas Reimbursement program
  • Distributes transit tickets when appropriate and tracks utilization
  • Confirms that all drivers eligible for gas reimbursement meet program criteria and that invoices are paid appropriately
  • Works closely with the Transportation and Quality Assurance departments to ensure smooth coordination of the potential clients to the bus
  • Maintains an open line of communication with superiors and co-workers, facilities and public transit systems
  • Creates and maintains spreadsheets showing 12 month goals and projected cost savings
  • Performs other duties as required

Licensed Insurance Associate

GEICO
01.2017 - 11.2017
  • NYS Licensed Agent
  • Strong customer service skills, a high independent resolution rate and collections
  • Strong telephone skills
  • Strong Multi tasking capabilities
  • Sold and serviced Auto policy holders, underwriter, direct agent
  • Handle confidential information
  • Proficiency with internet applications and sales

Senior Account Manager

ALM Media LLC
01.2012 - 01.2016
  • Sell Print and online Media Magazines to Law firms and Lawyers
  • Work with prestigious Martindale Hubbell AV Rated List of Lawyers
  • Met and exceeded individual monthly, quarterly, and annual sales goals
  • Qualified prospective clients by phone
  • Use consultative sales skills to assess clients goals, propose, and obtained commitment
  • Managed relationships with established clients and construct space reservations and I/O's within selling guidelines to develop and maintain a book of business
  • Communicate ongoing clients and sales activities utilizing Outlook and Excel, Sales Force
  • Provide ongoing and up-to-date documentation to the operations team and regularly collaborate strategies
  • Handle and resolve customer service issues related to advertising sales matters, large revenue contacts and billing
  • Facilitate and coordinate team meeting and projects on a revolving basis
  • Coordinate pages and projects with production and credit departments to achieve desired sales and customer service results

Outside Sales Manager

Gannett Media
01.2011 - 01.2012
  • Aggressively researched, developed, and cultivated leads for Double Take Deals using a variety of online and offline sources
  • Met and exceeded individual monthly, quarterly, and annual sales goals
  • Qualified prospective clients by phone and close deals in-person
  • Use consultative sales skills to assess merchant goals, propose a customized Double Take Deals solution, and obtained commitment
  • Managed relationships with established clients and construct proposals and contracts within selling guidelines to develop and maintain a book of business
  • Communicate ongoing contacts and sales activities utilizing Outlook
  • Provide ongoing and up-to-date documentation to the operations team and regularly collaborate best deal strategies

Sales Manager New Media online and Print - Automotive Sales

The Long Island Press
01.2010 - 01.2011
  • Company Overview: Syosset, NY
  • Managed 6 people, set goals, lead team meetings, went on Sales calls with Sales Reps to dealerships in Nassau and Suffolk Counties
  • Also partnered with car.com selling online
  • Coordinate, prepare and deliver presentation for various products delegating projects to appropriate sales directors
  • Sell online and print-to web advertising to clientele and advertising agencies
  • Deliver necessary feedback and ideas to Directors and VP for ongoing changes within our department
  • Syosset, NY

Outside Sales Executive Online/Print New Media Sales

Newsday, Inc.
01.2004 - 01.2010
  • Company Overview: Melville NY
  • Manage and grow a multi-million dollar Territory of Automotive clients
  • Present and sell various Newsday products, including Optimum Autos, to Automotive Clients and Agencies
  • Adhere and comply with strict copy deadlines for the newspaper, always under heavy pressure
  • Coordinate, prepare and deliver presentation for various products delegating projects to appropriate sales assistants
  • Sell online and print-to web advertising to clientele and advertising agencies
  • Deliver necessary feedback and ideas to management for ongoing changes within our department
  • Handle and resolve customer service issues related to advertising sales matters, large revenue contacts and billing
  • Facilitate and coordinate team meeting and projects on a revolving basis
  • Coordinate pages and projects with production and credit departments to achieve desired sales and customer service results
  • Melville NY

Commercial Sales Representative

01.1998 - 01.2004
  • Worked with Automotive dealers and General Managers within a set geographical territory
  • Discussed pre-owned budgets
  • Sold various Newsday products such as Wednesday/Saturday Photo packages and various Agate programs
  • Forecast and exceeded sales goals in territory on a quarterly basis
  • Received inbound calls as well as cold called to produce new business and territory growth year over year
  • Worked in field as required, developing strong customer relationships
  • Exercised strong customer service skills and patience dealing with angry customers for wrong Ads and errors

Classified Advertising Sales Development Representative

01.1992 - 01.1998
  • Received inbound calls in a Call center environment for various types of Classified Advertising
  • Sold Recruitment, Real Estate, Automotive, Immigration ads and Liquor license Ads, to name a few
  • Performed above company standards, for timely call answering and handling
  • Up sold each inbound call to meet quarterly sales goal
  • Cold called during slow season to grow sales and revenue
  • Assisted Management in understanding and revising necessary changes in methodology used within department to improve department performance
  • Knowledge and adherence to strict copy and policy changes, rate structures, and presented them to customers as win/win situations

Education

Regents Diploma -

Half Hollow Hills High School West

Bachelor of Science - Business Administration

University of Buffalo
Buffalo, NY

Computer knowledge courses, Excel, Microsoft Word, Powerpoint

Katherine Gibbs School
Melville, NY

Skills

  • Conflict resolution
  • Customer satisfaction
  • Dispute mediation
  • Problem solving
  • Case management
  • Communication skills
  • Client relations

References

Available upon request

Certification

  • Presentation Skills I
  • Presentation Skills II
  • Needs Based Selling
  • Telephone Selling Skills
  • Expressing Yourself Part I
  • Expressing Yourself Part II
  • Writing Advantage
  • Myers Briggs Type Indicator
  • HIPAA Law
  • NY State E Paces
  • NPI
  • Tax ID

Skillsinterestsawards

Strong customer service skills, Proficiency with internet applications, Advanced Windows applications (Word, Excel, PowerPoint), Typing, shorthand, word processing, Active member of Alpha Kappa Alpha Sorority, Inc., Active member of the Urban League, Sales person of the Year Award 1998 and 2003, Member of the Presidents Club For Q1, Q3, Q4 - 2007, Highest overall Quota in all of Classified New Media Advertising 2009, Logisticare Employee of the month 9 months in a row, Northwell Health Outstanding Service Employee highlight

Timeline

Senior Pharmacy Resolution Specialist

Centene Corporation
01.2023 - Current

Senior Eligibility and Prescription Claims Account Mgr.

Cigna
01.2022 - 01.2023

Senior Health Advocate4me E&I

United Healthcare
01.2021 - 01.2022

Financial Services, Advisor

Northwell Health
01.2019 - 01.2021

Customer Service Representative (CSR) -Router -Mass Transit Specialist

Logisticare, LLC
01.2017 - 01.2019

Licensed Insurance Associate

GEICO
01.2017 - 11.2017

Senior Account Manager

ALM Media LLC
01.2012 - 01.2016

Outside Sales Manager

Gannett Media
01.2011 - 01.2012

Sales Manager New Media online and Print - Automotive Sales

The Long Island Press
01.2010 - 01.2011

Outside Sales Executive Online/Print New Media Sales

Newsday, Inc.
01.2004 - 01.2010

Commercial Sales Representative

01.1998 - 01.2004

Classified Advertising Sales Development Representative

01.1992 - 01.1998

Regents Diploma -

Half Hollow Hills High School West

Bachelor of Science - Business Administration

University of Buffalo

Computer knowledge courses, Excel, Microsoft Word, Powerpoint

Katherine Gibbs School

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Pamela S. Jeffers