Shianna Peters
Brooklyn,NY
Summary
Diligent professional with top skills in customer care, conflict resolution and claims data entry. Recognized for resolving customer complaints with integrity and professionalism to maintain customer satisfaction and retention. Motivated team player committed to contributing to company success goals.
Overview
14
14
years of professional experience
Work History
Customer Care Representative III
Capital Rx
New York, NY
11.2020 - Current
- Provided accurate, valid, and complete information to customers via inbound and outbound calls.
- Followed up on customer inquiries not immediately resolved by providing timely updates on the status of their requests.
- Resolved customer complaints promptly and professionally.
- Maintained up-to-date knowledge of company policy and procedures.
- Generated reports summarizing daily claim activity for management review.
- Provided assistance in developing new processes and policies related to claim processing.
- Analyzed claim information to determine the appropriate course of action to ensure proper claim processing.
- Submitted claims electronically or via paper format, as required, in our JUDI platform.
- Assisted with training new staff members on proper procedures for claim processing.
- Managed multiple tasks simultaneously while meeting established deadlines and departmental metrics.
- Addressed customer inquiries to provide information and explanations on coverage and terms, expediting claims.
- Analyzed benefits and claim to apply appropriate benefit amounts.
- Reviewed patient records to ensure accuracy of information and completeness of documentation for Medicare claims processing.
- Validated Medicare eligibility requirements for beneficiaries prior to submitting claims.
- Performed periodic audits of Medicare-submitted claims, ensuring compliance with regulations.
- Tracked and review all incoming payments from the internal finance department to ensure accuracy of reimbursement payments.
Pharmacy HelpDesk Subject Matter Expert
Cognizant Technologies Solutions
New York, NY
06.2016 - 11.2022
- Investigated customer complaints in order to determine root cause then implemented corrective action plans accordingly.
- Managed customer inquiries with a focus on providing timely resolutions while maintaining excellent customer service levels.
- Provided subject matter expertise during meetings with senior leadership team members in order to discuss potential opportunities or challenges.
- Created multimedia presentations with PowerPoint and video conferencing tools.
- Designed and developed training materials for new employees in the organization.
- Documented all training activities including attendance records, feedback forms, surveys.
Pharmacy Ops and Medical Management Analyst
EmblemHealth
New York, NY
12.2012 - 06.2016
- Identified opportunities for process improvements across the organization.
- Collaborated with cross-functional teams on projects related to analytics initiatives.
- Identified needs of customers promptly and efficiently.
- Assessed customer complaints to determine eligibility for appeal or grievance filing.
- Analyzed complex cases to determine appropriate resolution in accordance with relevant laws, regulations and organizational policies.
- Reviewed and processed medical and pharmacy for all lines of business with a specific focus on Medicare Part B&D claims to ensure accuracy of information.
- Provided training and guidance to new claims processors on department procedures.
Customer Service Representative
EmblemHealth
New York, NY
10.2010 - 12.2012
- Engaged in conversation with members to understand needs, resolve issues and answer product questions.
- Verified member insurance coverage and eligibility for prescription medications.
- Adhered to all HIPAA regulations regarding patient privacy and confidentiality.
- Enhanced productivity and customer service levels by anticipating needs and delivering outstanding support.
- Liaison between members and retail/mail/specialty pharmacies to expedite orders and meet customer demands.
Education
Bachelor of Arts - Liberal Studies
Medgar Evers College of The City University of New York
Brooklyn, NY05-2010
Skills
- Customer service excellence
- Insurance Coverage Verification
- Regulatory compliance understanding
- Medicare Knowledgeable
- Medical and Pharmacy Claims Processing
- CMS Audit knowledge
- Internal Auditor/process verifier
- Proficient in Microsoft Office Suite
Timeline
Customer Care Representative III
Capital Rx
11.2020 - Current
Pharmacy HelpDesk Subject Matter Expert
Cognizant Technologies Solutions
06.2016 - 11.2022
Pharmacy Ops and Medical Management Analyst
EmblemHealth
12.2012 - 06.2016
Customer Service Representative
EmblemHealth
10.2010 - 12.2012
Bachelor of Arts - Liberal Studies
Medgar Evers College of The City University of New York
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