Tamika White

Served as a first-line advocate assisting members and providers by resolving routine inquiries,

concerns,

and service issues across multiple communication channels.

Delivered timely, accurate, and personalized support via phone, live chat, and emalil in a fast-paced

contact center environment.

Resolved complaints at the initial point of contact to prevent escalation and ensure positive customer

experiences.

Acted as a front-line resolution specialist addressing various member and provider questions, requests,

and concerns.

Assessed member and provider needs, identified root causes, and determined when issues required

escalation to other departments.

Maintained strong performance and met quality metrics established by the contact center, including

accuracy, timeliness, and customer satisfaction.

Documented all interactions thoroughly in CRM systems for tracking, quality assurance, and pertormance

review.

Stayed current with policies, regulations, and quality standards to ensure consistent and compliant service delivery.

• Streamlined claim settlements and appeals prioritizing high-volume tasks and managing deadlines to enhance provider satisfaction and reduce turnaround times.
• Reduced claim denials and optimized revenue cycles by collaborating with providers on accurate authorization submissions and advising on state-specific fee schedules (CPT codes), Medicare/Medicaid guidelines, and timely filing requirements.
• Conducted comprehensive reviews of denied claims, identifying discrepancies and gathering documentation from carriers and providers, leading to successful reversals on appeal.
• Managed complex provider inquiries, verifying NPIs (NPPES Registry), explaining EOPs (Explanation of Payments), and resolving recoupment issues via Cost Recovery/Claim Shark.
• Enhanced documentation accuracy by implementing best practices for case notes and tracking, ensuring compliance with industry regulations.
• Cross-trained in multi-state claims processing and supported special projects, including data breach remediation.

Option 2: Focus on Appeals, Denials & Compliance (High Impact)

Appeals & Claims Resolution Specialist | [Company Name]

• Expedited the appeals process, conducting thorough reviews of denied claims and liaising with carriers to secure reversals.
• Improved claim accuracy and reduced denials by proactively guiding providers on coding discrepancies, authorization requirements, and policy updates.
• Maintained 100% compliance with industry regulations and state guidelines while documenting cases and managing complex recoupments.
• Strengthened client relationships through transparent communication, expert guidance on Medicare/Medicaid policies, and timely resolution of inquiries [1, 2, 3].

Option 3: Focus on Provider Relations & Service (Service Heavy)

Provider Services Representative | [Company Name]

• Served as primary support for high-volume providers, delivering prompt updates on claim status, eligibility, and COB (Coordination of Benefits).
• Built trust and loyalty by resolving concerns, explaining payment breakdowns, and educating providers on policy changes [1].
• Acted as a liaison between clinical teams, insurance carriers, and providers to facilitate smooth documentation flow and faster authorizations.
• Supported specialized claim processing, assisting with complex cases and cross-functional projects to improve patient experience.

• Answered questions about eligibility determinations and plan options.
• Maintained confidentiality of all employee information.
• Helped address client complaints through timely corrective actions and appropriate referrals.
• Interacted with multiple insurance companies to verify the clients eligibility and benefits.
• Logged client conversations, policy information and changes in client information at time of each phone call made.
• Served as subject matter expert in answering questions from colleagues regarding benefits.
• Educated clients on products over phone, highlighting changes in policies.
• Educated customer's of their reward programs and eligibility coverage.
• Emailed customers on steps on registration or regarding other matters of their benefits.
• Updating customers information into the correct data base.
• Scheduling appointments with Quest for customers
• Assisting the user with navigating the website.
• Adhered to HIPAA policy and employer policies.

• Delivered exceptional customer service to every customer by leveraging extensive knowledge of products and services and creating welcoming, positive experiences.
• Investigated and resolved customer inquiries and complaints quickly.
• Recommended products to customers, thoroughly explaining details.
• Responded proactively and positively to rapid change.
• Resolved diverse range of technical issues across multiple systems and applications for customers and end-users across various time zones.
• Submitted service tickets for equipment maintenance requests.
• Used ticketing systems to manage and process support actions and requests.
• Researched product and issue resolution tactics to address customer concerns.
• Explained security measures in simple terminology to help users understand malware and phishing threats.
• Assisted customers in identifying issues and explained solutions to restore service and functionality.
• Provided documentation on troubleshooting of technical processes to support desk staff.
• Provided Tier 1 IT support to non-technical internal users through desk side support services.

• Accurately documented, researched and resolved customer service issues
• Filed multi vehicle car accident
• Exposed the proper coverage when needed
• Defused volatile customer situations calmly and courteously
• Answered an average of 32-50 calls per day by addressing customer inquiries, solving problems and providing new product information
• Processing new insurance policies, modifying existing ones and obtaining information from policyholders to verify the accuracy of their accounts
• Thoroughly review insurance policy and informed the member of the proper coverage that he or she may have regarding the claim.

• Managed high call volume, providing prompt assistance to providers seeking help with their healthcare services.
• Improved providers satisfaction by providing timely and accurate information on claim status and resolution.
• Reduced turnaround time for claim settlements by prioritizing tasks and managing deadlines effectively.
• Collaborated with cross-functional teams to expedite complex claims investigations and resolutions.
• Maintained compliance with industry regulations by adhering to established procedures and guidelines in claims handling.
• Developed strong relationships with clients, facilitating trust and open communication during the claims process.
• Served as a subject matter expert on specialized claims, providing guidance and support to other team members when needed.
• Expedited the appeals process for faster resolutions by streamlining procedures and workflows.
• Conducted comprehensive reviews of claim denials, identifying errors or discrepancies that led to successful reversals on appeal.
• Liaised with healthcare providers and insurance carriers to gather necessary documentation for appeal cases, leading to more informed decisionmaking.
• Implemented best practices for documenting case notes, improving record-keeping accuracy, and aiding team members in tracking progress on ongoing cases.
• Continuously monitored changes in healthcare policies affecting appeals processes, ensuring adaptability in response to evolving requirements.
• Obtained additional documentation required for case review.
• Entered appeal requests in appeals module.
• Collaborated with healthcare providers to ensure accurate and timely submission of authorization requests, resulting in reduced claim denials.
• Worked closely with clinical teams to gather needed information in a timely manner, supporting optimal patient care delivery.
• Participated in cross-functional projects aimed at improving the patient experience throughout their treatment journey.
• Contacted clients about verifying account information and updated services, answered questions and resolved concerns to uphold exceptional customer service standards and promote brand loyalty.
• Advised providers of timely filing to submit a corrected claims per state requirements.
• Advised providers why their claims were denied and the next steps per state guidelines.
• Advised providers of Medicare and Medicaid Guidelines.
• Confirmed members eligibility with primary and secondary insurance, updating and confirming coordination of benefits.
• Explained Explanation of Payments.
• Verified providers NPI's through the NPPES NPI Registry.
• Assisting providers with recoupments of claims through Cost Recovery and Claim Shark.
• Crossed trained to process claims with different states, worked on special projects regarding data breach.
• Advised providers each state Fee Schedule per CPT codes.
• Collaborated with healthcare providers to expedite the process of obtaining necessary medical documentation for approvals.
• Increased accuracy of insurance coverage validation by utilizing available tools and resources to verify eligibility requirements quickly.
• Maintained up-to-date knowledge of industry trends, regulatory changes, and payer-specific guidelines to ensure accurate processing of requests.
• Fielded telephone inquiries on authorization details from plan members and medical staff.
• Obtained and logged accurate patient insurance and demographic information for use by insurance providers and medical personnel.
• Tracked referral submission during facilitation of prior authorization issuance.
• Prepared and distributed denial letters, detailing reasons for denial and possible appeal measures.
• Triaged unscheduled and emergency authorizations, directing submissions to appropriate personnel for rapid response.
• Input all patient data regarding claims and prior authorizations into system accurately.
• Responded to inquiries from healthcare providers regarding prior authorization requests.
• Evaluated clinical criteria for approval or denial of services requiring pre-authorization.
• Researched denied claims and contacted insurance companies to resolve these issues.
• Verified medication authorizations and denial reasons in CVS Caremark.