Tiffany Riggs
Ocilla,GA
Summary
Applied extensive knowledge of CPT/ICD-10 coding and HIPAA regulations to interpret insurance policies and enhance patient care in dynamic healthcare settings.
Overview
2
2
years of professional experience
Work History
Pharmacy Benefits Manager
Optum rx
San Diego, CA
08.2025 - 11.2025
- Facilitated communication as primary contact for members, providers, and pharmacies regarding pharmacy-benefit inquiries.
- Evaluated and processed prior-authorization requests for medications, ensuring compliance with clinical documentation from prescribers.
- Analyzed pharmacy benefit plan design elements, including deductibles, copays, co-insurance, step therapy, tiering, and formulary exclusions, to assess eligibility and benefit entitlement.
- Addressed and resolved pharmacy claim issues, including coordination of benefits, claim overrides, and appeals. Assisted in processing reimbursements and managing mail-order pharmacy operations.
- Ensured accurate documentation and data management in benefit administration systems regarding member issues, claim status, prior authorizations, overrides, appeals, and utilization.
Claims Processor
Concentrix
Jacksonville, FL
06.2023 - 03.2025
- Achieved accurate processing of medical claims by conducting comprehensive reviews for completeness and eligibility. Validated member eligibility and policy terms, ensuring precise coding and adherence to coverage limits. Enhanced claim validity assessments through detailed verification of CPT and ICD-10 codes.
- Analyzed and resolved claims by applying necessary payment adjustments, corrections, or denials, maintaining accurate and effective communication with both providers and members.
- Managed resolution processes for exceptions and inquiries by systematically gathering missing information and engaging with providers, members, and internal teams to ensure thorough documentation and swift resolution.
- Monitored and evaluated performance metrics to meet quality, accuracy, and productivity benchmarks while ensuring compliance with HIPAA guidelines.
Education
Associate of Science - Health Information Technology
Wiregrass Georgia Technical College
Fitzgerald, GA05.2026
Skills
- Assisted in managing time effectively to meet project deadlines
- Supported documentation review processes using Microsoft Word
- Aided in claims processing by applying medical terminology knowledge
- Utilized Microsoft Excel for data organization and analysis Gained experience in medical office operations and medical billing procedures
Timeline
Pharmacy Benefits Manager
Optum rx
08.2025 - 11.2025
Claims Processor
Concentrix
06.2023 - 03.2025
Associate of Science - Health Information Technology
Wiregrass Georgia Technical College