Phillipa Robertson

Performs training for new and existing employees. Assist coordinators with any questions. Log, tracks, and processes health service appeals.

Serve as a liaison in corresponding with providers or members during the appeals process.

Interacts with other departments including Customer Service, Claims, Provider Relations and Pharmacy to resolve member and provider appeals.

Makes administrative appeal determinations when indicated and properly sets up case files for clinical review when needed.

Conducts general appeal research

Request waivers of liability and/or appointment of representative forms, request member medical records, Prepare written summaries, scheduling the case, processing the review of the case, documentation of the appeal resolution and send completed case file to external review organizations as required by regulatory guidelines.

• Managed high-stress situations effectively, maintaining professionalism under pressure while resolving disputes or conflicts.
• Resolved customer complaints with empathy, resulting in increased loyalty and repeat business.
• Handled escalated calls efficiently, finding satisfactory resolutions for both customers and the company alike.
• Responded to customer requests for products, services, and company information.
• Research claims processing guidelines to determine root cause of error.
• Assist providers with all claim issues and provide appeal and claim status.
• Investigate and resolve customer inquiries and complaints in a timely manner.

Resolves provider reconsideration requests on denied claims.

Handles written response to incoming reconsideration request.

Research claims processing guidelines to determine root cause

Monitor each request to ensure all internal and regulatory timelines are met .

• Enhanced customer satisfaction by effectively addressing and resolving member issues.
• Built strong relationships with clients by maintaining consistent follow-up and providing personalized support services tailored to their needs.
• Implemented performance metrics to monitor and evaluate team productivity and effectiveness.
• Provided regular coaching and feedback to team members.
• Developed training materials to ensure consistent onboarding and professional development of new team members.
• Managed escalated customer concerns, ensuring timely resolution and positive outcomes.
• Perform quality audits monthly.
• Assist supervisors with any projects.
• Complete and send out monthly coaching worksheets.