Summary
Overview
Work History
Education
Skills
Certification
Timeline
Generic

Rose Asante

Louisville,KY

Summary

Successful individual with 8 years' experience in Health Insurance field and Medical Call Centers. Post Appeals processing, Inbound/outbound Call Center, Insurance Claims, Health Case Managements and HEDIS. Implementing company's policy and procedure for successful, bottom line. Time management, phone etiquette, and great Clients turnaround on calls and cases. Looking to obtain a full-time position with an established company. Utilizing my knowledge and skills to contribute to the growth of the company as well as gain more knowledge.

Overview

11
11
years of professional experience
1
1
Certification

Work History

Post Service Appeal Specialist

L3 Humana, Inc.
Louisville, KY
05.2020 - 09.2023
  • I worked at Humana, Inc., remotely for a total of three years and four months.
  • Two years in inbound calls as Provider Care representatives.
  • One year and four months as a CMS Appeals & Grievances Certified Specialist in the Post Service Department.
  • As a Post Service Appeal Specialist, I was assigned an Appeal Case per workloads.
  • Responsibilities included multitasking using multiple computer screens, reading appeal letters from providers, members, and other related work field stuff.
  • All work occurs within a context of regulatory compliance, CMS policies, Humana appeals, and determinations guidelines.
  • Utilizing MEDHOK to initiate the appeal process flow, until the case is overturned, upheld, exhausted appeal rights, or decision to discontinue the process flow and transfer the case to another department within the company.
  • Other responsibilities included checking providers' network status using a tool called PAR-tool, for the purposes of establishing a sufficient network of Medicaid and Medicare participation.
  • Member Insurance eligibility and benefits, Read SOBs, retrieve Medical Records, sent Medical Records request to providers, and other filed staff.
  • Assuring cases were submitted timely per CMS and Humana guidelines.
  • Call provider/members via phone systems to obtain additional information pertaining to cases.
  • Other tools used were Medical Records Management, Image Viewer Station, NPI Registry, Salesforce Solution, Teams, CRM database, and phone systems, preferred.
  • And other tools provided by the Employer.
  • Documents all activity in MEDHOK, attends continuing education programs.
  • And other duties as assigned.

HEDIS Specialist

Anthem, Inc.
Louisville, KY
11.2019 - 04.2020
  • As a HEDIS specialist, my duties were to contact providers regarding members' BMI metrics/charts information and medical records for the annual review.
  • Had to interact with office managers, medical records specialist, and providers.
  • Call providers' offices and asked questions related to healthcare effectiveness, data, and information set.
  • Send requests for records to Providers.
  • Enter information in the system.
  • Follow up with providers about the status of the HEDIS documents.

Case Manager

McKesson
Louisville, KY
01.2019 - 08.2019
  • My duties were to answer inbound calls from pharmacies, providers, and patients regarding prior authorization, benefits, medication information, etc.
  • Duties include reviewing and explaining claims summary of benefits information to callers, overriding for prior authorization.
  • Using different systems and Process Patients applications.
  • Other duties: Prepare insurance claim forms or related documents, and review them.
  • Calculate the amount per contract and fee schedule for claims.
  • Post or attach information to claim file.
  • Transmit claims for payment or further investigation.

Patient Account Representative

Firstsource
Louisville, KY
08.2017 - 05.2018
  • Coordinate communication between patients, family members, medical staff, administrative staff, or regulatory agencies.
  • Interview patients or their representatives to identify problems relating to care.
  • Maintain knowledge of community services and resources available to patients.
  • Refer patients to appropriate healthcare services or resources.
  • Investigate and direct patient inquiries or complaints to appropriate medical staff members, and follow up to ensure satisfactory resolution.

Customer Service Representative

Teleperformance
Louisville, KY
03.2015 - 04.2017
  • Record information about the financial status of customers and the status of disputes.
  • Locate and monitor compromised accounts, using computers and a variety of automated systems.
  • Process disputes case, closed compromised cards, and issues new cards, and process claims.
  • Advise customers of necessary actions and strategies for debt securities.

Receiving Specialist

Amazon
Louisville, KY
03.2013 - 03.2015
  • Examine shipment contents and compare with records, such as manifests, invoices, or orders, to verify accuracy
  • Requisition and store shipping materials and supplies to maintain inventory of stock
  • Prepare documents, such as work orders, bills of lading, or shipping orders, to route materials
  • Pack, seal, label, or affix postage to prepare materials for shipping, using hand tools, power tools, or postage meter
  • Record shipment data, such as weight, charges, space availability, damages, or discrepancies, for reporting, accounting, or recordkeeping purposes.

Education

High School Diploma -

Western High School
Louisville, KY
05.2005

Skills

  • Insurance Claim Forms Review
  • Post Appeals processing
  • Eligibility Determination
  • Customer Service Skills
  • Team Collaboration
  • Excellent Communication
  • Number-savvy
  • Task Prioritization
  • Problem-solving abilities
  • Documentation skills
  • Allocating claims
  • Insurance terminology
  • Multitasking
  • Professional Demeanor
  • Medical Terminology
  • Application Review
  • Patient Rapport
  • Skilled in [Software]
  • Anatomy Knowledge
  • CRM Database
  • Salesforce
  • Insurance Claims
  • Medical Records Management content management system
  • Excel PowerPoint multiple windows system outlook fax machine
  • Case Management
  • Inbound/outbound Call Center
  • Health Case Managements
  • Well experienced in
  • Regulatory Compliance
  • Image Viewer
  • ICD9/CPT Coding
  • Organizational skills
  • Self Motivation
  • Time management abilities
  • Decision-Making
  • Background in insurance
  • Outstanding clerical abilities
  • Insurance plan verification
  • Regulatory Compliance Adherence
  • Understanding of medical terms
  • Electronic authorization processing
  • Insurance Coverage Verification
  • Policy Review
  • Problem-solving aptitude
  • Coverage Determination
  • Medicaid knowledge

Certification

  • CMS Appeals & Grievances Certificate, 02/01/23, Present
  • CMS Part C Organization Determinations Appeals & Grievances, 02/01/23, Present
  • Licensed Resident Agent for Health Insurance since April 2017 (7 years)

Timeline

Post Service Appeal Specialist

L3 Humana, Inc.
05.2020 - 09.2023

HEDIS Specialist

Anthem, Inc.
11.2019 - 04.2020

Case Manager

McKesson
01.2019 - 08.2019

Patient Account Representative

Firstsource
08.2017 - 05.2018

Customer Service Representative

Teleperformance
03.2015 - 04.2017

Receiving Specialist

Amazon
03.2013 - 03.2015

High School Diploma -

Western High School

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Rose Asante