Shironda Grider
Orlando,Florida
Summary
Licensed Insurance Verification Specialist bringing extensive call center experience in inbound, outbound and blended environments. Strength in problem solving, research, verifying patient
eligibility, coordinating benefits, running test claims and determining patient
coverage/responsibility for major medical and pharmacy services.
Overview
19
19
years of professional experience
Work History
Licensed Insurance Verification Specialist (AdvancedTherapy)
AllianceRxWalgreensPrime Specialty Pharmacy
Orlando, Florida
02.2016 - Current
- Verifying patient eligibility, coordinating benefits, running test claims and determining patient coverage/responsibility for services including, but not limited to primarily major medical insurance benefits verification, complex insurance plan verification and high volume PBM plans.
- Maintained patient accounts by processing new patient referrals, conducting benefit verification while verifying their active current prescription coverage, collecting patients copay structures and loading patients deductible, out of pocket, prior authorization information, co-pay assistance information into Scriptmed.
- Triaged referrals to correct pharmacies when a pharmacy is out of network.
- Handled Medicare part B, D, Medicaid, Commercial and Private Pay patients.
- Initiated the prior authorizations/pre-determinations for insurance to get verified and processed correctly.
- Communicated with both patients and primary care physicians (PCP's) and/or specialists in regards to standings.
- Communicated with patients about their estimated out of pocket payments.
- Assisted in training of new team members and acted as a resource for colleagues, providing up-to-date information on QRG's, policies, processes, and general contact center issues.
- Coordinated the work of Insurance Verification specialists.
- Provided notification of urgent orders to the Senior level or Group Supervisor and communicates with other departments when an urgent need for filling a prescription or delivery is necessary.
Patient Care Coordinator (SME)
Prime Therapeutics Specialty Pharmacy
Orlando, Florida
12.2014 - 02.2016
- Resolved complex patients' inquiries, while ensuring policies and procedures are followed.
- Assisted with patient's activities, including follow-up calls for patient's next order/refill.
- Contacted patient's doctor's office to schedule deliveries.
- Prioritized and resolved order issues including working with shipping vendors/third party logistics to track lost or undelivered shipments and merchandise returns.
- Assisted in training of new team members and ongoing staff training.
- Provided input to the supervisor regarding employees performances.
- Participated in Special Projects including, Error Reporting.
- Resolved complaints escalated by the Patient Care Coordinators consistent with service and quality standards.
- Provided valuable information resource and a wealth of knowledge and support to agents, such as up-to-date information on a specialty, policies, processes, quality, and general contact center issues.
Licensed Insurance Verification Specialist (SME)
CVS Caremark Specialty Pharmacy
Orlando, Florida
08.2013 - 11.2014
- Coordinated the work of Insurance Verification specialists.
- Resolved more complex issues related to patient coverage/responsibility for services.
- Verified patient's insurance coverage of medications, administration supplies and related pharmacy services.
- Completing the Prior Authorization process with insurance companies and practitioner offices.
- Completing a full Medical Verification for all medications, administration of supplies and related pharmacy services.
- Made outbound calls to patients or physicians' offices to obtain additional information needed to process the script or to notify of delay in processing script.
- Managed inbound calls in the insurance department phone que from patients, clients, physicians, practitioners and clinics regarding inquiries about services provided such as, financial responsibility and insurance coverage.
- Contacted patients, physicians, practitioners and/or clinics of any financial responsibility of services provided and requested services that are not provided by the pharmacy.
- Facilitated pharmacy and/or major medical claims with insurance companies and practitioner offices.
- Assisted in training of new team members and acted as a resource for colleagues.
Pharmacy Care Specialist
CVS Caremark Specialty Pharmacy
Orlando, Florida
08.2012 - 08.2013
- Provided patient support by coordinating deliveries of specialty medications, explanation of benefits, reviewing copay information, processing claims, obtaining payment method, assuring patient is compliant in therapy.
- Researched and resolved all patient issues and concerns such as delivery delays.
- Contacted UPS call center to initiate "Call Tag" pick up or re-route delivery or reship delivery if applicable.
- Utilized all available information to choose the best solution and resolve customer concerns.
- Directed complex questions and problems to more senior staff level.
- Used a computer application to log and track inquiries, as well as, to check the status of items that require follow-up or involvement of other parties.
- Documented customers interactions, record details, complaints, comments and actions taken.
- Referred unresolved customer grievances to designated departments for further investigation.
- Contacted customers to respond to inquiries or to notify them of investigation results and planned adjustments.
Dietary Aide
Emory L. Bennett Veterans Nursing home
Daytona Beach, Florida
12.2010 - 07.2012
- Preparation, delivery, and collection of patient food trays.
- Maintaining sanitation/safety conditions and provides assistance in other areas as required
- Partnered with team of registered nurses to achieve overall well-being of all patients.
- Completed all daily living tasks to enhance the quality of life of elderly patients.
- Transported patients to and from different departments.
- Ensured safety and well-being of patients.
- Followed infection control procedures.
- Demonstrated ability to lead and motivate outstanding healthcare teams.
Pharmacy Care Specialist
Walgreens Central Pharmacy Operation, PCC
Orlando, Florida
11.2007 - 11.2010
- Received inbound and outbound calls to patients or MD Offices regarding orders for medications, pharmacy services and all other inquiries.
- Coordinated patient care by scheduling orders, communicating information to the patient regarding shipments, assessing supply needs, verifying patient information, notifying the pharmacist of issues or changes in the patient's condition.
- Provided correct information or directed the call to the appropriate team member or department while maintaining a high level of professionalism.
- Created patient activities as a reminder for the following tasks including but not limited to follow-up calls for patients, to initiate discharge of service, to contact a patient's doctor's office, to mail a letter to a patient, and any other reminders necessary as it relates to a patient's care.
Customer Service Representative
Convergys
Lake Mary, Florida
01.2007 - 10.2007
- Handled inbound and outbound calls in a high pace, friendly call center environment.
- Greeted customers in a courteous, friendly, and professional manner using agreed upon procedures.
- Confirmed customers understanding of the solutions and provide additional customer education as needed.
- Updated customer records.
- Troubleshoot, researched and analyzed customer problems.
- Maintain broad knowledge of products, pricing, promotions, procedures, and other important issues through management communications, meetings, client focus groups, and formal training.
- Assisted customers with billing inquiries, changing rate plans, features and processing upgrades.
Education
Bachelor of Science - Biology/Pre-medicine
Bethune Cookman University
Daytona Beach, FloridaMay 2012
Skills
- Self-motivated and work with minimal supervision
- Excellent Customer Service Skills
- Strong organizational, analytical, interpretive, problem solving and time management skills
- Accomplished leader
- Promotes positive behavior
- Excellent at making consistent and unbiased decisions
- Planning and development
- Twelve years customer service experience
- Eleven years call center setting experience
- Nine years specialty pharmacy experience
- Proficient in Microsoft Office including Word, Excel & PowerPoint
- 70WPM Typist
- Experience building and maintaining relationships within a team
- Excellent in research
- Extremely experience with successfully applying de-escalation techniques
- Excellent at working under strict timelines with while managing priorities simultaneously
- Excellent Team leadership
- Excellent written and verbal communication skills
- Flexible, willing to take on more responsibilities as needed, and devote time necessary to complete deadlines
- Experience in indirect management of team members, including assisting in the development, training and assignment of work/projects to other team members
- Experience in diagnosing, isolating, and resolving complex issues and recommending and implementing strategies to resolve problems
- Experience in coaching, mentoring, and training staff
- Experience in providing training and developing process documentation/user manuals
Timeline
Licensed Insurance Verification Specialist (AdvancedTherapy)
AllianceRxWalgreensPrime Specialty Pharmacy
02.2016 - Current
Patient Care Coordinator (SME)
Prime Therapeutics Specialty Pharmacy
12.2014 - 02.2016
Licensed Insurance Verification Specialist (SME)
CVS Caremark Specialty Pharmacy
08.2013 - 11.2014
Pharmacy Care Specialist
CVS Caremark Specialty Pharmacy
08.2012 - 08.2013
Dietary Aide
Emory L. Bennett Veterans Nursing home
12.2010 - 07.2012
Pharmacy Care Specialist
Walgreens Central Pharmacy Operation, PCC
11.2007 - 11.2010
Customer Service Representative
Convergys
01.2007 - 10.2007
Bachelor of Science - Biology/Pre-medicine
Bethune Cookman University