Tonya Brown
Jacksonville,FL
Summary
passionate professional with commitment to supporting clients in all aspects of cases. Excellent communication and relationship building skills with diverse audiences. Friendly and engaging with strong team collaboration abilities.
Overview
19
19
years of professional experience
1
1
Certification
Work History
Provider Advocate/Escalated Claims Processor
Aetna/CVS
Jacksonville, FL
05.2015 - 10.2024
- Negotiated settlements between parties in dispute.
- Conducted research into applicable laws, regulations, and precedents.
- Reviewed documents related to cases for accuracy and completeness prior to filing them with the court.
- Reviewed claims for HMO, Traditional(PPO), JCA, Passport(international plans) Medicare, and Student Health plans.
- Conducted reviews of provider contracts to identify exceptions to claims payment policies, provider deviations, timely filing, and correct rates according to CPT and HCPC codes.
- Provided timely communication to providers regarding resolution of escalated claims submitted by Network Representatives.
- Generated appeal requests for denied claims
- Ensured all applicable referrals and authorizations for billed services were on file.
- Managed and updated spreadsheets for hospitals, addressing unresolved claim issues outside the capacity of the provider call center.
- submitted claims to the executive team for claims that could not be resolved in my department
Provider Call Center Representative/Senior Representative
Aetna
Jacksonville, FL
12.2005 - 05.2015
- Monitored call queues in order to prioritize incoming calls by urgency or importance level.
- Analyzed data collected during each call in order to identify trends in customer feedback.
- Utilized knowledge base to answer inquiries from customers quickly and effectively.
- Performed follow-up calls as necessary to ensure satisfactory resolution of customer inquiries.
- Followed standard processes and procedures for proper escalation of unresolved issues to appropriate internal teams.
- Assisted customers with navigating the company's website to locate desired information or items for purchase.
- Maintained accurate records of customer interactions for future reference.
- Resolved customer complaints in a timely manner to ensure customer satisfaction.
- Developed effective working relationships with team members across multiple departments.
- Attended regular training sessions on updates and changes within the industry or organization.
- Maintained high levels of professionalism while interacting with customers via phone or email.
- Maintained records of customer interactions, transactions, comments and complaints.
- Adhered strictly to all applicable laws and regulations pertaining to customer privacy rights.
- Updated customer accounts, addresses and contact information within call management databases.
- Resolved customer inquiries, questions and concerns to consistently offer quality service and meet performance benchmarks.
- Met or exceeded call speed, accuracy and volume benchmarks on consistent basis.
- Maintained strong call control and quickly worked through scripts to address problems.
- Delivered fast, friendly and knowledgeable service for routine questions and service complaints.
- Handled escalated customer service concerns to preserve customer satisfaction and maintain long-term business relationships.
- Answered incoming calls and provided highest level of professionalism and knowledgeable service to every customer.
- Consulted with customers to resolve service and billing issues.
- Navigated through computer systems to review information and respond appropriately to callers.
- Offered resolutions to de-escalate calls and solve customer issues.
- Engaged actively with callers, confirming or clarifying information and diffusing anger.
- Increased customer satisfaction ratings by effectively answering questions, suggesting effective solutions, and resolving issues quickly.
- Promoted high customer satisfaction by resolving problems with knowledgeable and friendly service.
- Kept records of customer interactions or transactions, thoroughly recording details of inquiries.
- Improved product knowledge on continuous basis to provide optimal service and achieve sales quotas.
- Mentored junior team members and managed employee relationships.
- Coordinated with internal teams to ensure timely and successful delivery of solutions according to client needs.
- Engaged in conversation with customers to understand needs, resolve issues and answer product questions.
- Provided feedback on ways to improve the overall customer experience.
- Acted as an escalation point for complex issues requiring additional resources or expertise.
- Ensured compliance with industry regulations regarding customer service standards.
- Coordinated special projects within the department as assigned by management.
- Analyzed customer data to identify trends and develop strategies for improvement.
- Trained new hires on customer service processes and protocols.
- Resolved escalated customer complaints in a timely manner.
- Monitored customer feedback to identify opportunities for improvement.
- Mentored junior staff members in providing excellent customer service.
- Assisted customers with product selection, order placement, and billing inquiries.
- Confirmed that customers received efficient resolution to problems by researching issues and providing adequate information.
- Assisted professionals with mentoring trainees in specific tasks and corporate procedures.
- Utilized broad knowledge to recommend solutions to potential customers.
- Demonstrated exceptional service skills by going above and beyond to satisfy customers on phone and in person.
- Answered questions and resolved concerns for customer support.
- Implemented customer retention strategies to minimize turnover and build loyalty.
- Displayed strong telephone etiquette, effectively handling difficult calls.
- Participated in regular team meetings to discuss performance, strategies, and goals.
- Managed client accounts, ensuring satisfaction and retention through regular communication and problem resolution.
- Identified needs of customers promptly and efficiently.
- Set specific goals for projects to measure progress and evaluate end results.
- Analyzed key performance indicators to identify effective strategies.
- Evaluated needs of departments and delegated tasks to optimize overall production.
- Maintained positive working relationship with fellow staff and management.
- Utilized document management system to organize company files, keeping up-to-date and easily accessible data.
Education
High School Diploma -
Jean Ribault High School
Jacksonville, FL06-1984
Skills
- Training delivery
- Policy Development
- Client Representation
- Mentorship
- Research proficiency
- Benefits Administration
- Analytical Reasoning
- Document Review
- Database Maintenance
- Attention to Detail
- Team Collaboration
- Discovery and Document Review
- Conflict Resolution
- Creative and Critical Thinking
- Decision-Making
- Building Trust and Relationships
- Document Management
- Problem-solving aptitude
- Task Prioritization
- Continuous Improvement
- Organizational Skills
- Excellent Communication
- Policy Knowledge
- Professional Demeanor
- Problem-Solving
- Problem-solving abilities
- Interpersonal Communication
- Knowledge of Federal and State Laws
- Collaboration and Teamwork
- Self Motivation
- Time management abilities
Accomplishments
- Trained and succeeded in the promotion to Senior representative. which included, being and acting supervisor where I handled escalated provider calls, assisted the seasoned representatives and new hires with call center provider/members benefit and claim calls. I assisted in the new hire trainings on all products and systems.
Certification
- I trained and work on the claims and benefit systems. ASD provider and claims system, Genelco(student health), Rumba system for HCPC and Dx Code rules, claims overpayment systems, Availity provider information systems
- training for workplace Code of Conduct and Compliance, weekly update training on system and coding updates, corporate records management program, conclusion and assessment skills, company discrimination and harassment training, preventing workplace violence, security awareness training
Timeline
Provider Advocate/Escalated Claims Processor
Aetna/CVS
05.2015 - 10.2024
Provider Call Center Representative/Senior Representative
Aetna
12.2005 - 05.2015
High School Diploma -
Jean Ribault High School