Talitha Stephens
Hightstown,NJ
Summary
Seasoned Customer Service Specialist with a solid background in resolving customer concerns, maintaining high satisfaction levels, and implementing effective solutions. Knowledge of processing claims and claim edits, explaining benefit breakdowns to members/providers, EOBs, customer care, customer complaints, billing, sales, and troubleshooting. Known for strong communication skills, problem-solving abilities, and a commitment to providing exceptional customer service. Proven capability in creating impactful relationships with customers, thereby fostering brand loyalty and repeat business. Skilled at successful customer interaction tactics to enhance overall service quality.
Overview
13
13
years of professional experience
Work History
Customer Care Specialist
Zelis Healthcare
, USA
09.2024 - Current
- Assist healthcare providers by researching their inquiries and providing solutions
- Ensure all member interactions are documented accurately in the system
- Analyze and resolve complex service issues and escalate when necessary
- Collaborate with team members to improve service processes and member satisfaction
- Attempt first call resolution through provider education
- Required to meet specific call center performance metrics of productivity and quality assurance
Member Services Representative
Commonwealth Care Alliance
, USA
12.2023 - 09.2024
- Respond and effectively triage member phone calls to accurately and timely route to appropriate area
- Provide accurate information regarding member benefits and services available as well as protocols and requirements, including continuity of care and initiating prior authorizations
- Complete comprehensive appeal and grievance intakes
- Attended to erroneous member billing discrepancies
- Assist with member mailings and respond to questions about mailings
- Responsible for providing members with any requested documents
- Assist with timely resolution of quandaries or complaints conveyed by members
- Responsible for acting in compliance with HIPPA, state and federal regulations when assisting members
- Meet and exceed departmental expectations, benchmarks, goals, and key performance indicators
Provider Service Professional
Imagine360
, USA
09.2022 - 07.2023
- Deliver above and beyond service over multiple channels by acting as a single point of contact for providers, maintaining ownership of first call resolution
- Display expert benefit administration information and alternative benefit payment designs, specifically reference based pricing
- Explain health benefit coverage, including accumulators, out of pocket maximums, reimbursement levels and explanation of benefits
- Treat all calls and correspondence using policy and procedures, paying attention to the sections related to HIPPA guidelines and privacy rules
- Maintain company service level guidelines (AHT, adherence) as well as maintain required quality control scores
- Responded promptly to emails sent by providers concerning billing inquiries or other related matters
- Maintained detailed records of client communications in the company's database system
Claims Representative
United Medical Resources
, USA
12.2021 - 09.2022
- Thoroughly review, analyze, and research complex healthcare claims to identify discrepancies, verify pricing, confirm prior authorizations, and process them for payment
- Navigating across various computer systems to locate critical information while showing attention to detail to ensure accuracy, which will support timely processing of the member's claim
- Consistently meet established productivity, schedule adherence and quality standards
- Documented changes in claim statuses using specialized software systems
- Collaborated with other departments to resolve billing disputes or address customer concerns quickly
- Ensured timely submission of required documentation from claimants prior to approval of payment
- Provided clear explanations of benefits, eligibility requirements, and applicable laws when communicating with customers
- Handled customer inquiries regarding insurance policy coverage details and payment status updates
- Processed a high volume of claims efficiently while maintaining quality standards
- Resolved complex discrepancies in policyholder files to facilitate accurate claim processing
- Maintained detailed records of all communication with customers, claimants, providers, and internal departments
- Provided quality customer service to assigned, insured and claimants throughout claims process to deliver timely service to customers
Call Center Representative
Navient
, USA
04.2021 - 12.2021
- Performed outbound calling campaigns to contact residents in the state of New Jersey as part of the effort to protect everyone from Covid-19, also received incoming calls
- Collect necessary patient information to register and process the public for the Covid-19 vaccine as well as follow up appointments for the second dose
- Utilized knowledge base to answer inquiries from customers quickly and effectively regarding the Covid-19 vaccine
Customer Service Representative
DataStaff
, USA
09.2020 - 03.2021
- Received incoming calls from consumers, prospective enrollees, and brokers inquiring about enrolling in health plans
- Asking probing questions to determine the level of coverage needed while completing the application process for new healthcare coverage
- Processed initial payments for health care coverage
- Respond to all inquiries consistent with confidentiality and privacy policies
- Maintained up-to-date knowledge of all programs and systems
- Exceeded Quality Assurance (QA) and other key performance metrics
- De-escalated problematic customer concerns, maintaining calm, friendly demeanor
Clerk
United States Postal Services
Trenton, USA
02.2012 - 06.2017
- Bundle mail in preparation for delivery or transportation to relay boxes
- Sort mail for delivery, arranging it in delivery sequence
- Sold stamps, weighed parcels, and being personally responsible for all money and stamps
- Check mail to ensure correct postage and that packages and letters are in proper condition for mailing
- Sort outgoing mail according to type and destination
- Picked up first class mail and ensured they were processed for the correct zone
Education
High School Diploma -
Daylight Twilight High School
06.2003
Skills
- Analytical Thinking
- Issue Research, Escalation & Follow Up
- Complaint Resolution
- Inbound and Outbound Calling
- Account Updating
- Microsoft Office Suite Expertise
- Software/Systems: Zoom, Teams, Zendesk, Slac, Epic, Onbase, Zelis, Repay, ECW, Skygen, Navitus, Looker, Salesforce, CRM Software
- Medical Terminology Knowledge, ICD-9 codes, ICD-10 codes, CPT/HCPCS codes
Timeline
Customer Care Specialist
Zelis Healthcare
09.2024 - Current
Member Services Representative
Commonwealth Care Alliance
12.2023 - 09.2024
Provider Service Professional
Imagine360
09.2022 - 07.2023
Claims Representative
United Medical Resources
12.2021 - 09.2022
Call Center Representative
Navient
04.2021 - 12.2021
Customer Service Representative
DataStaff
09.2020 - 03.2021
Clerk
United States Postal Services
02.2012 - 06.2017
High School Diploma -
Daylight Twilight High School
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