Hi, I’m
Shammara Hayes
Healthcare Advocate
Oviedo,FL
Summary
Resident Licensed -240, Healthcare advocate with a career currently spent accurately managing records, handling Provider assignments,care coordination appointment scheduling, and complaints and grievances in a fast-paced remote setting. Detail Oriented individual committed to engaging others and delivering exceptional service. Ready to approach new challenges in an remote/home based environment.
Overview
4
years of professional experience
Work History
Teletech Health Solutions: United HealthcareOrlando, FL
Member Service Representative
05.2023 - Current
Job overview
- Addressing member inquiries, questions, and concerns in all areas including enrollment, claims, benefit interpretation, coordination of benefits ,and referrals/authorizations for medical and prescription care.
- Responsible for providing one call resolution and proactive follow up to increase member satisfaction.
- Provide all requirements and limitations for benefits and requests .
- Research,escalate, appeal , or submit grievances of issues as appropriate to provide positive outcomes.
- Maintain confidentiality per HIPAA guidelines.
- Manage customer conflicts and challenging situations by maintaining call control and accessing internal knowledgebase to develop strategic solutions.
- Help members resolve health plan services ,community resources,or plan issues and navigate internal systems to handle needs.
- Offer exceptional customer service to differentiate and promote company brand.
Teletech Health Solutions: Blue Cross Blue Shield
Provider Customer Advocate
05.2022 - 04.2023
Job overview
- Gathering, reviewing, and verifying all pertinent information relating to participating healthcare providers.
- Establishing and maintaining relationships with contracted and non contracted healthcare providers through prompt resolution of medical benefit verification , verification of ICD-10 codes,CPT, and HCPCS codes, Appeals,Medical necessity processes,utilization management , and Prior authorization requirements .
- Gathering, reviewing, and submitting relevant documentation needed for pre-service claims processing in and out of network ,and post service denial.
- Maintaining effective channels of communication with service Providers while meeting client requirements and Mandated Health care guidelines.
Teletech Health Solutions: Kaiser PermanenteOakland, CA
Transmission Prevention Specialist (Covid-19)
12.2020 - 05.2022
Job overview
- Processed orders for quarantine care kit that included critical supplies.
- Verifying shipping details to prevent duplicate orders.
- Referred members to Member services and clinical teams to assist in health-related questions, concerns, testing, and appointments.
- Counseled members on COVID-19 FAQ and educational material with status updates to increase awareness to household members,visitors,and the general public.
- Collaborated with healthcare providers to provide referrals for individuals seeking assistance such as community resources for employment, food,financial,housing,and mental health support.
Teletech Health Solutions: Kaiser PermanenteOakland, CA
Licensed Medicare Advantage Sales Specialist
10.2020 - 12.2020
Job overview
- Telesales of Medicare supplement insurance policies, which are designed to cover the costs of healthcare not covered by Part A or Part B of Medicare.
- Explained the benefits of Medicare Advantage plans, which allow subscribers to receive all their healthcare services through one company.
- Explained how Medicare works in conjunction with private insurance policies for those eligible for Medicare prospects.
- Verifying Medicare Part A/B eligibility through CMS/Marx System.
- Provided information about eligibility requirements for State and Federal government programs.
CVS Caremark
Pharmacy Customer Service Representative
11.2019 - 01.2020
Job overview
- Refilled medications, offered insight into over-the-counter products and verified insurance benefits.
- Assisted clearing high volume of wait time to fill prescriptions and responded to customer questions.
- Conducted reviews of medication orders for accuracy.
- Created new customer profiles and updated demographics, allergies and new medications in pharmacy computer systems.
- Adhered to all HIPAA regulations regarding patient privacy and confidentiality.
- Communicated effectively with physicians, nurses, patients and other healthcare professionals regarding medication needs or issues related to prescriptions.
Education
International Baccalaureate Magnet School
High School Diploma
University Overview
- Florida Health -240 License
Skills
- Strong Organizational Skills and Ability to Multi-Task
- Conflict Resolution
- Building Rapport
- Prior Authorizations and ICD-10, CPT, HCPCS Coding
- Appointment Scheduling
- Establish and Maintain Effective Working Relationships With Patients, Insurance Companies, and Staff
- Pharmacy and OTC benefits
- Medicare, Medicare Advantage, Medicaid Knowledge
- Ability to Demonstrate Patience, Empathy and Sympathy
- Strong Written and Oral Communications Skills
- Strong Knowledge of Medical insurance and Authorization Processes
- Experience Working in Healthcare or Insurance Environment
- Proficiency in Microsoft Office, Suite, Excel, Outlook, Power point
- Excellent Attention to Detail and Active Listening Skills
- Inbound and Outbound Calling
- Service Upselling
Timeline
Member Service Representative
Teletech Health Solutions: United Healthcare
05.2023 - Current
Provider Customer Advocate
Teletech Health Solutions: Blue Cross Blue Shield
05.2022 - 04.2023
Transmission Prevention Specialist (Covid-19)
Teletech Health Solutions: Kaiser Permanente
12.2020 - 05.2022
Licensed Medicare Advantage Sales Specialist
Teletech Health Solutions: Kaiser Permanente
10.2020 - 12.2020
Pharmacy Customer Service Representative
CVS Caremark
11.2019 - 01.2020
International Baccalaureate Magnet School
High School Diploma
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