Philana Wilson
Automated Health Systems
Murfreesboro,TN
20
years of professional experience
Healthcare Customer Service Professional experienced in managing customer interactions and resolving issues efficiently. Built strong customer relationships through effective communication and empathy, resulting in high customer satisfaction and loyalty. Committed to delivering exceptional service and enhancing customer experiences.
Work History
Customer Service Representative II
3 Years- Educated new and existing members on TennCare program details to enhance understanding and access to services.
- Facilitated processing of new applications, renewals, and inquiries for members over the phone, ensuring timely assistance.
- Clarified Notice of Decision for callers, aiding in their understanding of case outcomes.
- Facilitated the appeal process for members to ensure fair assessments.
- Maintained and updated case information to reflect current member status.
- Handled voluntary termination requests from members to ensure proper documentation.
- Executed daily processing of verification, application, renewal, and review tasks.
Customer Service Representative
3 Years 10 Months- Handled inbound calls and emails from members and providers regarding benefits.
- Confirmed member eligibility, termination dates and plan types.
- Advised and educated on deductible, out of pocket limits and accumulations.
- Provided guidance on processed claims and the reasons for any denials. including denials.
- Resolved denied claims by providing clear, actionable guidance to members.
- Researched and resolved member and provider related issues.
- Educated members on appeal submission processes to enhance understanding and compliance.
- Coordinated communication between multiple departments to effectively address and resolve member issues.
- Navigated multiple systems and screens to assist members and providers.
Pharmacy Customer Service Representative
3 Years 1 Month- Guided and educated callers on their prescription benefits, use of plan, formulary, premiums and status of orders and claims or inquiries.
- Responded to incoming calls from our customers on issues related to benefit eligibility questions and prescription status inquiries.
- Identified issues and communicated solutions and steps to customers, pharmacies and physicians with prescription orders and reorders.
- Identified issues with prescription orders, communicated solutions and guided customers, pharmacies, and physicians through resolution steps.
- Conducted outbound calls to customers regarding prescription orders and payment issues, facilitating prompt resolutions.
- Assisted pharmacies with adjudicating claims by providing necessary processing information and PPS codes, ensuring timely resolution.
- Assisted physicians, prescribers with formulary alternative information, prior authorization, step therapy, quantity limit, etc.
- Trained agents on back end systems.
- Assisted in team and individual calibration sessions and provided feedback.
Scheduler
- Coordinated patient appointments to optimize scheduling efficiency.
- Confirmed, cancelled, and rescheduled patient appointments.
- Registered new patients and assisted existing patients.
- Provided referral information.
- Provided location details, fax numbers, and doctor availability to patients.
- Communicated messages to doctor's office and medical team.
- Provided referral information when needed.
- Leveraged multiple systems to streamline patient and doctor interactions.
- Maintained professionalism while dealing with patients' concerns or issues
Pharmacy Help Desk
1 Year- Assisted pharmacies in processing retail pharmacy claims and resolving claim rejections to ensure timely reimbursements.
- Provided processing information to pharmacies to help assist with claim processing.
- Answered pharmacy specific inquiries.
- Explained Prior Authorization procedures and Drug Utilization Review (DUR) messages to support pharmacies in compliance and patient care.
- Confirmed member eligibility status
Medical Billing and Coding Extern
- Answered multiple phones, took messages and accurately applied payments to patient accounts.
- Researched and resolved incorrect payments and other issues with outstanding accounts.
- Reviewed billing edits and submitted corrected information to insurance providers to resolve discrepancies.
- Conducted follow-up calls to confirm resolution of payment issues, ensuring accuracy in patient accounts.
- Recorded explanation of benefits and patient payments into the billing system.
- Entered charges from Encounter Forms and checked patient insurance availability.
Assistant Manager II
3 Years- Supervised day-to-day operations, ensuring smooth business functions
- Created and executed marketing campaigns to enhance brand visibility
- Resolved consumer complaints by actively listening and providing effective solutions. and provided customer service when needed
- Reported daily and monthly sales figures to Manager
Education
Associates - Medical Insurance Billing and Coding
Skills
Insurance eligibility verification
Document Management
Data management
Data Entry
Insurance verification
Microsoft Powerpoint
Critical thinking
Relationship building
Work Authorization
Authorized to work in the US for any employer
Personal Information
Work Permit: Authorized to work in the US for any employer
Timeline
Customer Service Representative II
Automated Health Systems
11.2023 - CurrentRead More
Customer Service Representative
Lucent Health Solutions
07.2019 - 05.2023Read More
Pharmacy Customer Service Representative
OptumRx - United Health Group
12.2015 - 01.2019Read More
Scheduler
Optum
01.2014 - 01.2014Read More
Pharmacy Help Desk
Optum
01.2013 - 01.2014Read More
Medical Billing and Coding Extern
Orchid Medical
01.2012 - 01.2012Read More
Assistant Manager II
Perfume Smart
01.2007 - 01.2010Read More
Everest University
Associates from Medical Insurance Billing and Coding
Read More