Tiara Clay
Louisville
Summary
Dedicated Healthcare Support Specialist with over 5 years of experience in Medicare and commercial member support within high-volume call centers and digital platforms. Translates complex benefits and claims processes into clear guidance, manages escalations, and ensures HIPAA compliance in EMR/CRM documentation. Enhances claims workflows and member satisfaction through effective communication, problem-solving, and collaboration.
Overview
3
3
years of post-secondary education
7
7
years of professional experience
Work History
Member Care Advocate
Included Health
09.2025 - Current
- Handled high-volume inbound calls and chats from members, providers, and vendors to ensure timely support.
- Explain health plan benefits, deductibles, copays, coinsurance, out-of-pocket maximums, and eligibility requirements.
- Assist with claims, billing questions, prior authorizations, and benefits inquiries.
- Assisted members in locating and verifying in-network providers and specialists to facilitate access to care.
- Guide members through enrollment and scheduling for healthcare programs and virtual care services.
- Investigated and resolved complex member issues, minimizing transfers and member effort for improved satisfaction.
- Document interactions accurately in CRM systems while maintaining HIPAA compliance.
- Meet quality assurance, productivity, and member satisfaction goals.
- Worked remotely to provide support and services to members.
Patient Support Advocate
KnipperRX
Louisville
08.2024 - 08.2025
- Assisted patients with medication access, benefit verification, prior authorization status, and patient assistance program requirements.
- Assisted patients with medication access, benefit verification, prior authorization, and patient assistance program requirements, ensuring seamless access to necessary therapies.
- Resolved complex patient inquiries through research, problem-solving, and collaboration with internal teams to ensure timely issue resolution.
- Coordinated with healthcare providers and specialty pharmacies to obtain required documentation and facilitate therapy initiation.
- Resolved complex patient inquiries through research, problem-solving, and collaboration with internal teams, achieving timely resolutions and enhancing patient satisfaction.
- Coordinated with healthcare providers and specialty pharmacies to obtain required documentation, facilitating prompt therapy initiation for patients.
- Managed high call volumes while consistently meeting quality, productivity, and service-level expectations.
Member Service Guide
Devoted Health
09.2024 - 05.2025
- Provided empathetic, high-quality support across phone, chat, email and video. Resolving benefits and care navigation questions while preserving member trust.
- Simplified complex plan language and claims processes into clear, actionable guidance for members and providers.
- Shifted seamlessly between inbound service, outbound outreach, and digital engagement, aligning with changing operational priorities.
- Ensured accurate EMR/CRM documentation and escalated clinical or coverage issues to clinical teams for prompt resolution.
Short Term Disability Claims Manager
Guardian Life Insurance
08.2021 - 09.2024
- Managed end-to-end short-term disability claims, ensuring accurate adjudication, regulatory compliance, and clear communication with claimants and providers.
- Investigated complex cases and led escalations
- Coordinated clinical reviews, vendor partners, and internal teams to reach timely resolutions.
- Improved claims workflows and documentation standards, streamlining handoffs and reducing rework while preserving member satisfaction and audit readiness.
- Trained and mentored teammates on policy interpretation, system use, and quality expectations, fostering a knowledgeable and efficient team.
- Worked remotely to support claims processing and communication with team members.
Customer Service Representative (Healthcare Call Center)
Humana
08.2019 - 08.2021
- Managed high-volume inbound and outbound calls, providing support to members with Medicare and commercial insurance, ensuring timely resolution of inquiries.
- Simplified complex healthcare information to guide members through benefits, referrals, and billing while maintaining accurate EMR documentation and balancing multiple systems in real time.
- Surpassed call handling and quality assurance metrics, resulting in high member satisfaction.
- Remote
Education
Bachelor of Science - Human Resource Management
Sullivan University
Louisville, Ky 07.2023 - 07.2026
Skills
- Healthcare navigation
- Healthcare regulations
- Customer relationship management
- CRM proficiency
- Process optimization
- Member engagement
- Client communication
- Empathetic listening & problem-solving
- Adaptability in fast-paced environments
Timeline
Member Care Advocate
Included Health
09.2025 - Current
Member Service Guide
Devoted Health
09.2024 - 05.2025
Patient Support Advocate
KnipperRX
08.2024 - 08.2025
Bachelor of Science - Human Resource Management
Sullivan University
07.2023 - 07.2026
Short Term Disability Claims Manager
Guardian Life Insurance
08.2021 - 09.2024
Customer Service Representative (Healthcare Call Center)
Humana
08.2019 - 08.2021