Rhonda Weaver
Lubbock
Summary
With over 20 years of experience in the Health Plan industry, I possess a deep understanding of Commercial, PPO, HMO, Medicaid, and Medicare plans. Currently, I am seeking new opportunities to utilize my expertise in this field. Specifically, I am interested in Customer Service Representative roles, where I can apply my excellent communication skills and dedication to delivering exceptional service.
Overview
21
21
years of professional experience
Work History
Insurance Specialist II
Abbvie Pharmaceuticals
06.2023 - 02.2025
- Built relationships with clients using active listening and issue resolution to provide excellent service.
- Enhanced customer satisfaction by addressing insurance-related inquiries and resolving issues promptly.
- Assisted physician offices through the entire documentation and filing process for prior authorizations and appeals. Monitored the status to ensure a rapid turnaround resulting in procurement of the drug product for the patient.
- Collaborated with health insurance payors and providers to investigate pharmacy and medical benefits.
- Met or exceeded department standards relative to performance metrics. Took responsibility and accountability for the day-to-day execution of tasks
- Ensured compliance with federal, state, and local pharmacy laws, HIPAA regulations, and company policies and
procedures. - Successfully completef all mandatory training, including soft skills certification, product knowledge, and disease
overviews. - Maintained confidentiality of patient finances, records, and health statuses.
Member Liason-Compliance/Sr, Member Advocate
Anthem, Inc. dba Amerigroup
11.2014 - 02.2022
- Responsible for the coordination of the Denials and Appeals process including tracking, trending, and reporting all denial/ appeals and for assuring that all regulatory, state, and contractual requirements are met.
- Responsible for providing specialized support for clinical compliance initiatives and regulatory/contractual requirements, member retention by investigation and resolution of member complaints, acting as liaison/mediator between the member, provider and Health Plan.
- Served as a liaison between the Health Plan, Member Services Representatives, State Agencies, and providers,
facilitating resolution of medical denials and appeals. - Acted as a subject matter expert, collecting critical documentation and information to address pharmacy-related complaints and issues.
- Guided members through the decision review and appeals process, ensuring clarity, transparency, and compliance.
- Utilized strong communication and conflict resolution skills to diffuse emotionally charged situations while
maintaining professionalism and rapport. - Collaborated across multiple departments, including Underwriting, Medical Investigations, Grievances & Appeals,Claims, Membership, and Legal, ensuring seamless issue resolution.
- Referred issues and concerns regarding members to the Case Management department as appropriate.
- Educated members and providers on Health Plan policies, programs, and services, addressing inquiries and providing
necessary guidance. - Documented and analyzed service interactions, providing management with insights for continuous service and
quality improvements.
Pharmacy Services Coordinator II
Firstcare Health Plans, Inc.
05.2006 - 11.2014
- Supported customer service teams in resolving member and provider prescription drug issues, ensuring efficient and
accurate claim processing. - Provided guidance and training to customer service staff on prescription benefits, formulary entries, and claim
resolution strategies, improving first-call resolution rates. - Reviewed daily eligibility reports and routed them to the appropriate internal teams for research and resolution.
- Educated customer service staff on pharmacy benefits and formulary guidelines, enhancing their ability to assist
members and providers effectively. - Managed communications with external vendors and customer service representatives regarding pharmacy policy
changes, both written and verbal. - Escalated complex prescription drug benefit inquiries to the appropriate internal or external departments for timely
resolution. - Coordinated internal resolution of pharmacy claims, including reviewing rejected claims and determining
appropriate corrective actions. - Assisted the clinical team with prior authorizations and Patient Assistance Programs, ensuring patients received
necessary medications. - Placed outbound calls to members and physicians to address prescription-related issues and facilitate resolutions.
- Monitored and tracked pharmacy complaints and grievances, ensuring all issues were addressed and resolved
efficiently.
Customer Service/Medicare Sales Representative
FirstCare Health Plans
03.2004 - 05.2006
- Engaged potential members by contacting leads and educating them on First Care Health Plans’ Medicare Advantage policies.
- Scheduled and conducted follow-up home visits, assisting both dual and non-dual eligible individuals in
understanding plan benefits. - Ensured compliance and transparency by documenting all materials presented during appointments to confirm the
potential member’s understanding. - Consistently met and exceeded monthly and quarterly sales goals until the Medicare Advantage sales program
transitioned to a local agency.
Education
Associate of Science - Accounting
South Plains College
Levelland, TexasSkills
- Effective communication
- Client relations expertise
- Flexible problem-solving
- Strong focus on accuracy
- Technology proficiency
- Creative problem resolution
Timeline
Insurance Specialist II
Abbvie Pharmaceuticals
06.2023 - 02.2025
Member Liason-Compliance/Sr, Member Advocate
Anthem, Inc. dba Amerigroup
11.2014 - 02.2022
Pharmacy Services Coordinator II
Firstcare Health Plans, Inc.
05.2006 - 11.2014
Customer Service/Medicare Sales Representative
FirstCare Health Plans
03.2004 - 05.2006
Associate of Science - Accounting
South Plains College
Similar Profiles
Zach FateZach Fate
Specialty Representative II at Abbvie PharmaceuticalsSpecialty Representative II at Abbvie Pharmaceuticals
Ashley Marie KilkearyAshley Marie Kilkeary
CNS Specialty Representative at Abbvie PharmaceuticalsCNS Specialty Representative at Abbvie Pharmaceuticals
Tom LoveTom Love
Senior HVAC Controls Technician at Abbvie PharmaceuticalsSenior HVAC Controls Technician at Abbvie Pharmaceuticals