Tonya Pride
Mansfield,OH
Summary
Well-rounded, motivated, dependable, and diligent professional with 5 years of experience in the healthcare sector, aiming to leverage a blend of expertise in healthcare practices and a solid medical education to pursue a fulfilling role within a progressive healthcare institution committed to innovation.
Overview
11
11
years of professional experience
1
1
Certification
Work History
Pharmacy Benefit Specialist
Prime Therapeutics, LLC
09.2024 - Current
- Respond promptly and professionally to inbound calls from members, pharmacies, and healthcare providers, delivering top-notch support and resolving inquiries related to prescription benefits, claims processing, and medication coverage.
- Accurately troubleshoot and resolve claims issues, including denials, prior authorizations, eligibility inquiries, and prescription processing problems.
- Verify insurance details, copay amounts, formulary information, medication coverage, and prior authorization requirements. Assist members and pharmacies with understanding their prescription benefits.
- Enter, update, and verify patient, pharmacy, and prescription information using UNITY EHR systems.
- Uphold HIPAA regulations and Prime Therapeutics’ guidelines to ensure the confidentiality and security of member information.
- Partner with internal teams, including pharmacists, claims departments, and clinical teams, to provide seamless support and resolution to members and providers.
- Collaborate with claims specialists to address coordination of benefits (COB) situations, ensuring accurate processing when members have multiple insurance plans.
- Actively communicate with pharmacies and healthcare providers to address potential processing delays, benefit changes, or claims adjustments.
- Demonstrate familiarity with Prime Therapeutics’ services, benefits offerings, medication guidelines, and insurance protocols to effectively support members and providers.
- Administered employee benefits programs, ensuring compliance with policies and regulations.
Data Entry Specialist
Activus Connect LLC
04.2023 - 05.2024
- Processed high volumes of data with accuracy, ensuring timely completion of projects.
- Utilized advanced data entry software to enhance efficiency and streamline workflows.
- Conducted quality checks on data entries, maintaining high standards of accuracy.
- Developed and implemented best practices for data management, reducing errors significantly.
Medical Office Scheduler / Billing
Summa Health
03.2021 - 04.2023
- Efficiently schedule and manage patient appointments using scheduling software.
- Coordinate healthcare providers' schedules to optimize patient care.
- Inbound and outbound calls, communicating with patients for appointment scheduling and providing excellent customer service.
- Address patient inquiries, send appointment reminders, and handle scheduling-related issues.
- Verify patient information and insurance coverage.
- Maintain accurate records of appointments and ensure adherence to confidentiality guidelines.
- Collaborate with healthcare providers and various departments.
- Coordinated scheduling for multiple departments to optimize resource allocation and operational efficiency.
Credentialing Specialist
Delta Dental
04.2020 - 05.2021
- Review and verify credentials of medical professionals.
- Maintain and update credentialing records and databases.
- Ensure compliance with regulatory and accreditation standards.
- Handle credentialing applications and renewals efficiently.
- Manage and resolve credentialing issues and discrepancies with medical staff via phone, and email.
Loan Specialist
Lendistry
10.2019 - 04.2020
- Review and process grant applications, ensuring completeness and adherence to eligibility criteria.
- Inbound and outbound calls, assisting applicants in understanding and completing required documentation for grant submissions.
- Communicate with potential grant recipients to provide information on available grants and application procedures.
- Ensure compliance with grant guidelines and regulations, including verifying eligibility and required documentation.
- Facilitated communication between clients and underwriters to expedite loan approvals.
Patient Support Associate
Ohio Health
08.2018 - 09.2019
- Greet and assist patients, visitors, and families in a professional and courteous manner.
- Answer phone calls, respond to inquiries, and direct individuals to appropriate departments or staff.
- Assist patients with registration, appointment scheduling, and check-in/check-out procedures.
- Provide support with patient navigation, ensuring individuals understand instructions, directions, and available resources.
- Maintain accurate and confidential patient records in compliance with HIPAA and organizational standards.
- Collaborate with clinical and administrative staff to support efficient patient flow and quality care.
- Handle patient concerns or complaints with empathy and escalate issues when necessary.
- Support the coordination of transportation, translation, or other patient services when required.
- Perform general clerical duties such as filing, data entry, and document preparation.
Billing Specialist
CenturyLink Corporate Office
07.2017 - 08.2018
- Prepare and issue invoices to customers accurately and promptly based on provided services or products.
- Reconcile billing statements and ensure accuracy in billing records, investigating and resolving discrepancies or issues as needed.
- Outbound calling, assisting customers or internal teams with billing-related inquiries, providing clarification on invoices, payment terms, or billing discrepancies.
- Record payments received, apply them to appropriate accounts, and follow up on outstanding balances.
- Maintain comprehensive and organized billing records, create reports detailing billing activities, and assist in financial reporting as required.
- Collaborate with other departments, such as sales, customer service, and finance, to address billing-related concerns and streamline processes.
- Ensure adherence to billing and accounting policies, as well as regulatory requirements, to maintain accuracy and integrity in financial transactions.
- Oversee claim processing, including verifying and validating claims, ensuring compliance with relevant policies and regulations, and resolving any issues or discrepancies.
Credit Card Specialist
J.P. Morgan Chase & Co
03.2015 - 06.2017
- Inbound calls, providing exceptional customer service by addressing inquiries, concerns, and requests related to credit cards promptly and professionally via phone, email, or in-person interactions.
- Handle credit card account maintenance tasks, including account openings, closures, limit adjustments, and updating customer information in compliance with regulations and policies.
- Process credit card transactions, including payments, refunds, and disputes, ensuring accuracy and adherence to company policies and industry regulations.
- Facilitate the issuance of new credit cards, replacement cards, or additional cards for authorized users, adhering to security protocols.
Education
Certificate - Medical Billing And Coding
Purdue Global University
10-2026
Associate of Science Degree - Health Sciences – Medical Administrative Assistant
Ultimate Medical Academy
04-2024
Skills
- Medical Administrative Assistant
- Medical Terminology
- Medical Transcription
- Patient Processing
- Patient Registration
- Medical Records Management
- Detail-oriented data management
- Release Of Information
- Prior Authorizations
- HIPAA Compliance
- Medical Laws & Ethics
- Benefits coordination
- Medicare/Medicaid
- Medical Billing
- ICD-10-CM Coding/CPT/HCPCS
- Expertise in healthcare benefits programs
- Written and Oral Communication
- Strong attention to detail
- Strong organizational skills
- Self-directed work
- Proficient in managing multiple tasks
- 10-key number pad expertise
Certification
Medical Administrative Assistant– UMA
Timeline
Pharmacy Benefit Specialist
Prime Therapeutics, LLC
09.2024 - Current
Data Entry Specialist
Activus Connect LLC
04.2023 - 05.2024
Medical Office Scheduler / Billing
Summa Health
03.2021 - 04.2023
Credentialing Specialist
Delta Dental
04.2020 - 05.2021
Loan Specialist
Lendistry
10.2019 - 04.2020
Patient Support Associate
Ohio Health
08.2018 - 09.2019
Billing Specialist
CenturyLink Corporate Office
07.2017 - 08.2018
Credit Card Specialist
J.P. Morgan Chase & Co
03.2015 - 06.2017
Certificate - Medical Billing And Coding
Purdue Global University
Associate of Science Degree - Health Sciences – Medical Administrative Assistant
Ultimate Medical Academy
Awards
Honors/Awards: Ultimate Medical Academy Honor Roll
Similar Profiles
Erica SheriffErica Sheriff
Supervisor of Initial Review Pharmacy Technicians at Prime Therapeutics LLCSupervisor of Initial Review Pharmacy Technicians at Prime Therapeutics LLC
Heather EppsHeather Epps
Business Analyst at Prime Therapeutics LLCBusiness Analyst at Prime Therapeutics LLC
Estella WhiteEstella White
Pharmacy Health Desk at Prime Therapeutics LLCPharmacy Health Desk at Prime Therapeutics LLC
Chantel Pauly MangrumChantel Pauly Mangrum
Logistics Manager at Hedstrom FitnessLogistics Manager at Hedstrom Fitness
Janet SwankJanet Swank
Home Health Aide at Cornerstone Caregiving & Help at HomeHome Health Aide at Cornerstone Caregiving & Help at Home