Ramona Grayson

• Provide empathetic support: Answer inbound calls and chats from members, providers,

• and vendors, ensuring each interaction is respectful, compassionate, and solutions-oriented

• Advocate for members by taking ownership of their healthcare navigation needs ,

• including: Assist members in resolving health plan-related questions, including claims and

• billing inquiries, prior authorizations, and benefits coverage.

• Facilitate access to virtual care services, second opinions from an expert, and other

• healthcare resources.

• researching and resolving complex cases to assist member with a resolution with their denied claims. Helped member understand their available benefits

•guiding them in accessing the services that best meet their needs .

• Examines and evaluates claims for payment of various compensations benefits under health, dental or other insurance programs
• Approves or denies claims as appropriate; initiates payment actions and makes adjustments to funds reserves as needed
• Investigates claims for compensability, potential subrogation and possible fraud
• Advises medical providers, claimants and others on rules, procedures, policies and laws of insurance programs
• Authorizes or denies medical and dental treatment, surgery, medical equipment, and training on other services
• Requests additional information, medical examinations or other actions
• Provided assistance in other departments such as 'Cost Recovery'; audits overpayments and/or initiates the overpayment process
• Prepares written responses, documenting information in the systems for tracking purposes, and follows up on the collection of claims overpayments
• Researched and responded to member/provider overpayment disputes
• Researched and applies money refunded by check or wire transfers
• Audits claims related to returned checks and Virtual Credit Card payments to determine the corrective action necessary

• Primary contact for college students and providers regarding claim status, coverage concerns, investigation of pre-existing conditions, eligibility and enrollment issues
• Assisted athletic trainers and athletes with injury claim submission online, and by fax or phone

• Answered customer inquiries via telephone as well as in person
• Documented calls, including but not limited to documentation of claim notes and follow-up written correspondence
• Handled billing inquiries, traced checks, processed stop-payment requests, and resolved problems
• Updated third party insurance
• Met and exceeded production and quality standards set forth by the department

• Contacted insurance companies to verify benefits prior to patient office visits and surgeries
• Obtained referrals and pre-certifications when required
• Notified financial counselors regarding accounts with outstanding debt
• Maintained records of patients' primary and secondary insurance
• Assisted eligible patients with obtaining medical insurance