TAMARA R. LYLES

• Performing preparation duties such as rinsing, peeling, slicing, and dicing fruit and vegetables.
• Weighing, and measuring ingredients.
• Wrapping, date-labeling, and storing food items on units.
• Cleaning and organizing work areas, equipment, utensils, and service station
• Following established recipes to prepare menu items, based on dietary restrictions
• Following guidelines to ensure correct serving temperatures and adequate portion control.
• Serving residents in a fast, efficient, and friendly manner
• Providing residents with information regarding food ingredients, availability, and pricing
• Assisting customers to pay for products within dietary restrictions.
• Complying with relevant safety, hygiene, and service standards and procedures

• Company Overview: (TPA through the Marketplace Exchange).
• Proficient in Microsoft Office Programs including Word, excel, powerpoint.

• Experienced in Multiple Claims Platforms Such as Facets, Cosmos, Nice, UNET.

• Ability to make positive impressions over the phone and build rapport.
• Communicated medical, and dental benefits breakdowns to providers.
• Provided outstanding customer service to providers, and members by giving detailed benefits, claims, disclaimers, and cob information.
• Communicated with the Marketplace to correct enrollment issues, and update member information.
• Initiated prior authorizations, and requested, and processed clinicals for review through care-one systems.
• Verification of potential, fraud, waste and error in claims reviews.
• Initiated first lever appeals for members, and providers.
• Ability to understand and assist in multiple insurance products, such as Medicare, Medicaid, Federal, and State of Maryland.
• Attain to Commercial and Medicaid/Medicare regulations.
• Ensure adherence to state and federal compliance policies, reimbursement policies and contracts.
• (TPA through the Marketplace Exchange).

• Company Overview: (Employee Engagement Committee Member).
• Analyzes and investigates potential fraud claims.
• Analyze and review medical records.
• Verification of potential, fraud, waste and error in claims reviews.
• Communicated medical, and dental breakdowns to providers.
• Ability to understand and assist in multiple insurance products.
• Attain to Medicare, Commercial and Medicaid regulations
• Ensure adherence to state and federal compliance policies, reimbursement policies and contracts
• Consult, and present findings with Clinical review team in regards to prior authorizations for inpatient, outpatient, as well as medications.
• Experienced in Multiple Claims Platforms Such as Facets, Cosmos, Iset.

• Reviewed Benefits, eligibility and claims with providers.
• Researched complex issues across multiple databases Iset, Emulator, Odars, Facets, and Optum 360.
• Ability to understand and assist in multiple insurance products.
• Met and establish productivity, adherence and quality standards.
• Ensured adherence to state and federal compliance policies, reimbursement policies and contracts.
• Communicated Effectively and Efficiently with Providers through phone, outlook (email) and Fax.
• Provided outstanding customer service to providers by ensuring first call resolution
• Promoted to Escalation team Lead for high dollar claim provider escalations, and resolution of claim issues using knowledge of current procedural terminology, ICD-9, and ICD-10 Codes.

• Managed a team, overseeing the training and integration of new staff members to ensure adherence to operational standards.
• Administered inventory and sales budgeting, effectively aligning resources with business needs and delivering reports to stock holders.
• Performed budgeting needs for inventory, and sales to present to franchise owners to increase productivity, and exceptional service.
• Maintained high levels of customer satisfaction by delivering superior service and fostering a positive environment for patrons and employees.