Shamauri Peoples

• Assist members and providers with benefits, copays, eligibility, claim inquiries, and authorization.
requirements.
• Review claim statuses, research discrepancies, and initiate claim reprocessing when necessary.
• Help members locate in-network providers based on plan benefits and geography.
• Provide authorization statuses and benefit clarifications to members and provider offices.
• Manage high volume inbound calls while documenting all interactions in internal systems.
• Utilize Microsoft Office and internal platforms to research and resolve member concerns.

Additional Team Support
• Support team chat by answering questions to maintain workflow efficiency.
• Respond to General Inquiry (GI) and dissent emails from members and providers.

Authorization Experience (Outside Primary Role)
• Completed internal Utilization Management (UM) authorization training.
• Assisted UM team during overtime and assigned to creating authorization cases during work hours.
• Identified and attached appropriate clinical documentation to member cases.
• Gained hands on experience with authorization workflows and case processing.

• Contacted clients with past due accounts to formulate payment plans and discuss restructuring options.
• Generated and submitted invoices based upon established accounts receivable schedules and terms.
• Worked effectively with medical payers such as Medicare, Medicaid, commercial insurances to obtain timely and accurate payments.
• Identified, researched, and resolved billing variances to maintain system accuracy and currency.
• Processed high-volume billing transactions efficiently and accurately, ensuring timely submission to clients.

• Researching and performing reasonable investigation on customer accounts related to billing errors or fraud claims.
• managing dispute/fraud caseload by researching, investigating, documenting, and resolving claims.
• utilizes Mastercard /Visa regulations to resolve customer claim.
• multi-faceted and requires high level of accuracy and attention to detail.
• Communication with customers via telephone and written correspondence is required.

• Answered incoming telephone calls promptly/transferring calls to appropriate department.

● Delivered exceptional customer service to every customer by leveraging extensive knowledge of

products and services and creating welcoming, positive experiences.

● Researched, calmed and rapidly resolved client conflicts prevent loss of key accounts.

● Managed quality communication, customer support and product representation for each client.

● Executed outbound calls to existing customer base resulting in 30% in sales.

● Guaranteed positive customer experiences and resolved all customer complaints.

• Provided primary customer support to internal and external customers.
• Improved daily operations, vendor relationships, contractor communication and employee remote access by streamlining processes.
• Researched issues through identification of similar past problems and recommended most appropriate solution.
• Approved and terminated customer contracts upon request.
• Managed over 50 customer calls per day