Summary
Overview
Work History
Education
Skills
Timeline
Generic

Tiffany James

Claims
Dallas,TX

Summary

Goal-Oriented Repricing claims Specialist, Senior Intake coordinator with Utilization Review Coordinator skills with over 16 years of great Customer service experience. Extensive knowledge of CPT codes, HCPCs, Possess advanced computer skills in utilizing Microsoft Office Word and Excel, and an intermediate knowledge of Microsoft Access and other reporting databases possess EDI knowledge, able to multitask, prioritize and work independently.

Authorized to work in the US for any employer Qualified

Overview

12
12
years of professional experience

Work History

External Pricing Configuration/Claims

WebTPA
08.2020 - Current
  • Maintain External Pricing configuration for group health plans:
  • Evaluate and manually price both professional and institutional medical claims with external vendors
  • Review and correct errors identified in keying medical claims
  • Communicate with networks to verify pricing information and resolve claim issues
  • Know/understand different provider specialties & types for accurate application to benefit plans
  • Add and approve provider and vendor records
  • Monitor claim flow through external networks & EDI Processes (80%) Execute communications both internally and externally:
  • Provide customer service externally to our clients, networks, providers
  • Provide customer service internally to our customer service, claims and account management departments

Intake Coordinator/ Utilization

eQHealth Solutions
08.2018 - 08.2020
  • Obtain and input initial demographics for inpatient and outpatient pre-certification
  • Accurate documentation of information obtained
  • Includes accurate communication of services requested
  • Screen calls appropriately and work with clinicians to ensure optimal turnaround times
  • Responsible for completing callbacks in an efficient manner
  • Print, correct and forward reports requested to nurses or supervisor
  • Responsible for managing all clinical faxes and ensuring all regulatory timelines are met
  • Identification of any errors within multiple systems utilized and forward to supervisor as indicated
  • Customer Service Tier ll

Patient Care Coordinator

Prime Therapeutics, Walgreens Prime Strategic Alliance
08.2017 - Current
  • Answer incoming calls, make outbound calls or complete orders from fax, emails and online order forms from members, pharmacies, doctor's offices
  • Complete requests forms for information on medication and benefits
  • Investigate and resolve member inquiries in a timely manner or escalate to appropriate departments,
  • Adhere to and reinforce departmental standard operating procedures and training guidelines specific to HIPAA
  • Run test claims for the patient insurance plans
  • Assist patients and there doctors office with finding co-pay assistance for there medication.

Support Specialist

WorldVentures - Travel
08.2016 - 08.2017
  • Answer incoming calls, emails and incoming chat from member's and representative's answering any questions or concerns that they have about the benefits or composition plan
  • Help the representative with their enrollments, event tickets or any questions they have about the members enrolled on their team
  • Assist members with updating their account information also processing their monthly payments
  • Take escalated calls (such a supervisor) from members or reps with issues on their account
  • Also, working with the V.I.P REPS taking their issues and resolving them or just answering any questions about their commission payout., 0780 | tiffanysjames@yahoo.com
  • Performed basic troubleshooting process by following a specific set of guidelines
  • Accurate and efficient order entry and maintenance of customer files
  • Asked probing questions and overcome objections

SALES/ CUSTOMER SERVICE REPRESENTATIVE

Comerica Bank
04.2015 - 06.2016
  • Meet or exceeds individual goals for sales and referrals; Provides remarkable customer service through all customer interactions
  • Opens new accounts, provides problem resolution, telephone answering, safe deposit access, etc
  • Develops an in-depth knowledge of consumer products and services; refers loans and deposit products to consumer and small business customers and prospects
  • Uncovers customer needs through the use of probing techniques and other sales tools
  • Conducts outbound calls by using referral sources, walk-in sources, telephone or in-person calls
  • Provides transactional customer service, including but not limited to the following: accept and process deposits, withdrawals and payments and handle other over the counter and mail transactions
  • Ensures compliance with applicable federal, state and local laws and regulations, and Comerica's policies and procedures; Ensure compliance and completion of necessary compliance related training
  • Adheres to all Banking Center audit and compliance standards

Education

No Degree - Medical Billing And Coding

Everest College
Dallas, TX

High School Diploma -

South Oak Cliff High School
Dallas, TX
05.2003

Skills

  • Claims Adjustments
  • Policy Knowledge
  • Customer Service
  • Authorization (Medical/Dental)
  • Pharmacy
  • Repricing medical and Dental claims
  • Microsoft word,Excel and access

Timeline

External Pricing Configuration/Claims

WebTPA
08.2020 - Current

Intake Coordinator/ Utilization

eQHealth Solutions
08.2018 - 08.2020

Patient Care Coordinator

Prime Therapeutics, Walgreens Prime Strategic Alliance
08.2017 - Current

Support Specialist

WorldVentures - Travel
08.2016 - 08.2017

SALES/ CUSTOMER SERVICE REPRESENTATIVE

Comerica Bank
04.2015 - 06.2016

No Degree - Medical Billing And Coding

Everest College

High School Diploma -

South Oak Cliff High School

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