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Phyllis Nelson
Healthcare
Cedar Hill,USA
Summary
Clinical care specialist skilled in patient advocacy and claims processing. Enhances member satisfaction through effective communication and problem-solving. Knowledgeable in CPT coding and HIPAA compliance, fostering strong relationships with healthcare providers. Focused on network development, contract negotiations, and stakeholder communication.
Overview
18
18
years of professional experience
Work History
Clinical Care Professional Senior Representative
United Healthcare
Irving, TX
05.2017 - 05.2025
- Assisted United Healthcare members in navigating health needs and developing care plans.
- Advocated for members with compassion, commitment, and integrity.
- Facilitated connections between members and primary care or behavioral health providers.
- Guided members through grievance and appeals processes, ensuring timely follow-ups.
- Discussed benefit information regarding covered services and medical equipment.
- Contacted medical care providers to assist with appointment scheduling and claims issues.
- Managed claims data to ensure billing accuracy and compliance.
- Maintained knowledge of business strategies and participated in required training sessions.
Document Scanner
Iron Mountain Records Management
Dallas, TX
04.2022 - 10.2022
- Scanned documents into digital format using specialized document scanner.
- Prepared documents for scanning by ensuring all staples and paperclips were removed.
- Managed document processes through scanning, filing and transmitting while following all standard procedures.
- Organized digital files in accordance with established naming conventions and file structure protocols.
- Managed archiving process, ensuring secure storage and easy retrieval of digital files.
- Ensured compliance with HIPAA regulations regarding storage and transfer of sensitive patient information.
- Collaborated with team members to achieve accuracy in document preparation.
- Assisted in developing best practices for document handling and processing.
- Maintained updated knowledge through continuing education and advanced training.
Clinical Administrative Coordinator Advocate 4ME
United Healthcare
Irving, TX
01.2017 - 12.2017
- Assisted members with benefit information and completed HRA/gaps in care assessments to facilitate access to necessary services.
- Located INN/PCP, vision, dental, and specialist providers for members to ensure timely and appropriate care.
- Assigned tasks to the member's Service Coordinator and contacted the member's doctor’s office to assist in setting up appointments.
- Managed STAR and MMP programs for member enrollment and support.
- Submitted DME and PAS requests for members requiring respite hours.
- Escalated member issues for delayed callbacks and urgent issues.
- Review and resolve claims issues/regarding dates of services/deductibles/reimbursement
- Maintain/Exceed required metrics of Quality and UES for bonus incentive
- Documented significant achievements in member advocacy and service delivery.
- Research and assign the PCP for members/ ID Cards/effective dates
- Managed global self-service HR transactions and requested access to IEX metrics.
- Systems use NDB, Facets, ICUE, CMS Marx
Private Nanny
Dr. K Thomas
Plano, Texas
05.2009 - 05.2017
- Provided attentive care and supervision for children in a private household.
- Developed engaging educational activities that enhanced child development and fostered a love for learning.
- Coordinated daily schedules for children's activities, meals, and rest times to ensure structured routines and promote well-being.
- Maintained safe, healthy, and nurturing environment that supported children's emotional and physical growth.
- Communicated effectively with parents regarding children's needs and progress.
- Implemented routines that fostered discipline, respect, and responsibility in children.
- Organized playdates and social activities to encourage social interaction among peers.
- Took children on outings such as parks, library visits, sports events or educational trips.
- Developed lasting, professional relationships with families by encouraging open communication and delivering positive feedback.
- Provided positive reinforcement through rewards systems for good behavior.
- Encouraged developmentally appropriate language skills through conversation and activities.
- Organized travel plans for vacation and overnight stays, including accommodations and itineraries.
Analyst I Servicing Support/Customer Service
Hyundai Capitol America
Plano, TX
01.2012 - 12.2016
- Assist in handling incoming calls on a daily basis for customers with billing questions, issues regarding their financial account; process payments, set up/disable auto pay for customers billing statements, title release information, state to state transfer.
- Advised customers on disclosures and educated members about lease-end obligations, inspection requirements, vehicle return expectations, end of term fees, and early lease termination information.
- Assisted customers with total loss by logging processes for titles, lien releases, and dealer buyouts.
- Communicated with dealerships, financial institutions, and insurance companies to obtain buyout quotes, title release information, refunds, and changes to payment extension due dates.
- Troubleshoot HMF/KMF website accounts explain simple interest/breakdown of how payments are applied.
- Performed 3rd party verification and managed account information.
- Processed property tax invoices for accuracy and compliance.
- Work efficiently and in an optimum level when calls are answered in a timely manner.
- Documented key accomplishments and contributions to team success.
- HYPER-Formance annual performance review exceeds business requirements.
- Assist with nesting and training of new hires.
- Assist leads with floor support /answering questions problem solving deescalating calls.
- Training remarketing /auto auctions.
- Organize and plan team functions and cultural events.
- Participated in welcome call committee to enhance onboarding experience.
- Systems used, Citrix-Leas Pak, Assurant (title & release info) BNY-Mellon, Tax matrix (sales & property tax) DSTO Siebel/CRM, Ryan-automate lease tax, CMS (imaging) Western Union Speed pay BNY-Mellon, Kana, Oracle, websites admin.
- Process GLB opt in/out affiliate marketing sharing.
Customer Service Representative/Front Lead
Humana
Dallas, TX
01.2011 - 12.2012
- Interacted with customers to address inquiries about products and services, enhancing customer understanding.
- Handled and resolved customer complaints, ensuring customer satisfaction and retention.
- Maintained detailed records of customer interactions to improve service quality and support future inquiries.
- Created documents, letters, or statements as requested by the customer.
- Explained how to use equipment and solve any equipment problems.
- Multitasking in a volume setting, effective communications problem solving and enrolled members in recommended programs and classes.
- Triage all incoming authorizations, coordinate authorizations with Healthcare Finder, nurse, and monitor authorizations.
- Identify and direct beneficiaries to the most appropriate, cost effective medical care.
- Register /Screen Medicare/Medicaid members for selected programs, such as: diabetes, healthy eating, cholesterol diet and exercise.
- Complete Health Assessments with members for annual health screenings. Enter processed returned assessments on excel spreadsheet daily.
- Performed medical coding and billing tasks accurately.
- Coordinated with the internal department to solve matters.
Customer Service Representative/ Data Entry/ Quality Control
DocuData
Dallas, TX
01.2007 - 12.2008
- Maximized reimbursement by ensuring accurate coding and conducting regular quality audits of providers' selected codes compared to chart documentation.
- Assigned and audited diagnostic and procedure codes to patient records, ensuring accuracy for reimbursement.
- Managed chart completion (coding/abstracting), assembly, and analysis to support compliance and quality standards.
- Reviewed medical documentation and consulted with healthcare providers to clarify inadequate or unclear coding information.
- Ensured records met quality and risk-management requirements by participating in hospital chart review committee.
- Provided ongoing training to staff on intricacies of insurance submissions, codes and intake procedures to minimize rejections for referral- or registration-related reasons.
- Key Accomplishments:
Education
Some College (No Degree) -
Wades Fashion Merchandising College
Dallas, TXSkills
- CPT coding and medical terminology
- Patient assessment and care
- Claims processing and billing procedures
- HIPAA compliance
- Client communication and interaction
- Customer service and support
- Epic system proficiency
- CRM systems expertise
- Productivity software knowledge
- Microsoft Office applications
- Data entry and office administration
- Scheduling management
- Computer operation skills
- Property insurance knowledge
- Attention to detail and problem solving
- Phone call management and interpersonal skills
- Communication skills and customer account management
- English proficiency
Company
United Healthcare
Languages
English
Additional Information - Work Authorization
Authorized to work in the US for any employer
Personal Information
- Willing To Relocate: Anywhere
- Title: Clinical Care Professional Senior Representative
Timeline
Document Scanner
Iron Mountain Records Management
04.2022 - 10.2022
Clinical Care Professional Senior Representative
United Healthcare
05.2017 - 05.2025
Clinical Administrative Coordinator Advocate 4ME
United Healthcare
01.2017 - 12.2017
Analyst I Servicing Support/Customer Service
Hyundai Capitol America
01.2012 - 12.2016
Customer Service Representative/Front Lead
Humana
01.2011 - 12.2012
Private Nanny
Dr. K Thomas
05.2009 - 05.2017
Customer Service Representative/ Data Entry/ Quality Control
DocuData
01.2007 - 12.2008
Some College (No Degree) -
Wades Fashion Merchandising College