Shy McGilberry
Des Moines,IA
Summary
Experienced in Wellmark products, benefit plans, claims processing, contract language, insurance rules, and regulations across various market segments. Skilled in managing and evaluating team and individual business outcomes using Power BI to monitor and achieve departmental and customer expectations. Proven ability to cultivate relationships with internal and external stakeholders. Thrives in a fast-paced, high-energy, and innovative setting, providing guidance to team members in a goal-oriented production environment. Collaborates closely with leadership and senior staff to synchronize operational processes with the company's strategic objectives. Demonstrates proficiency in Microsoft Office and Wellmark programs such as Frontier, FACETS, Compass, Word, Excel, and Outlook. Adaptable to working independently or as part of a team, exhibiting strong attention to detail, organizational skills, and prioritization to effectively complete assigned tasks. Skilled in handling member inquiries on specialized national group products while serving as a mentor for newly hired associates to support their growth and development within the organization.
Overview
9
9
years of professional experience
Work History
Pharmacy Support Specialist
WELLMARK INC.
11.2023 - Current
- Conducted training sessions for new employees.
- Manage appeals on formulary exception denials (independent review organization-IRO) requests for a non-formulary drug intake process and coordinate member and provider communications as a results of IRO decision.
- Perform outreach calls to members, pharmacies, and providers related to IRO decisions. Provide value-based customer experience through active listening and responding accurately, promptly, and professionally to member and provider questions. Manage difficult conversations that result in escalated interactions with professionalism and composure.
- Provide written communicate to members and providers that results in accurate understanding of IRO request outcomes.
- Research and timely respond to pharmacy inquiries received from Customer Service, Case Management, or benefits/eligibility questions from Sales. Ensure research and response is clearly communicated by responding accurately, promptly, and professionally.
- Responsible for the analysis and appropriate resolution(s) of pharmacy related inquiries and processing. Research, interpret and educate internal stakeholders or customer regarding the inquiry in question and then determine next steps required in order to accurately process pharmacy claims and outstanding questions.
- Regularly revised and managed drug and medical policy content on Wellmark.com.
- Collaborated with healthcare providers to resolve prescription-related issues and enhance member care.
Customer Experience Advocate II
WELLMARK INC.
05.2016 - 11.2023
- Promoted from Associate to Advocate I, and further promoted to CXA II. Research group members, group administrators, and all lines of business provider inquiries. Vast knowledge and understanding of eligibility, benefits, and claims. Educate members and providers on web tools, benefits, and claims processing. Effectively resolve escalated calls with business knowledge, commitment, and compassion. Develop relationships by listening and providing solutions to members, providers, agents and group administrators. Respond to inquires verbally and in written form via web. Provide team support utilizing my research and communication skills. Successfully and efficiently work from home and utilize Microsoft Teams to maintain relationships and keep lines of communication open with coworkers. Maintain quality scores at or above expectations.
Education
Diploma -
Roosevelt High School
05.2013
Certified Pharmacy Technician -
Des Moines Area Community College
Skills
- Insurance billing
- Healthcare regulations
- Workflow optimization
- Prior authorization assistance
- Pharmacy terminology
- Pharmacy operations
- Answering customer questions
- Data entry
- Insurance verification
- Resolving complaints
- Teamwork and collaboration
- Problem-solving
- Time management
- Attention to detail
- Problem-solving abilities
- Multitasking
- Critical thinking
- Organizational skills
- Customer relations
- Call center experience
- Computer proficiency
- Conflict resolution
- Microsoft Excel
- Microsoft outlook
- Product knowledge
- Team development
- Microsoft PowerPoint
- Prioritization
- Staff training
- Proofreading
Accomplishments
- Successfully accomplished provider web training and provided accurate responses.
- Completed training course for National group member inquiries.
- Successfully completed member web training.
- Medicare Supplement trained for primary skill.
- Chosen to assist with BlueCard inquiries.
Accomplishments
Incorporating cultural environment for workplace by adding Juneteenth and MLK as paid holidays for Wellmark
Achieved 100% for IRO compliance guidelines
Originated successful fun committee
Worked on special projects
Created desk level procedures
Timeline
Pharmacy Support Specialist
WELLMARK INC.
11.2023 - Current
Customer Experience Advocate II
WELLMARK INC.
05.2016 - 11.2023
Diploma -
Roosevelt High School
Certified Pharmacy Technician -
Des Moines Area Community College
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