Tristin Moore

• Receive inbound calls from members, providers, health plans and pharmacies. Enters pharmacy overrides into systems based on approved guidelines and approvals provided from clinical pharmacists

• Thoroughly researches issues and takes appropriate action to resolve them using the appropriate reference material within turnaround time requirements and quality standards

• Logs, tracks, resolves, and responds to all assigned inquiries and complaints while meeting all regulatory, CMS, and Centene Corporate guidelines in which special care is required to enhance Centene relationships, while meeting and exceeding all performance standards

• Maintains expert knowledge on all pharmacy benefits and formularies, including CMS regulations as they pertain to this position

• Responsible for knowing and interpreting pharmacy and medical benefits

• Answers and conducts inbound and outbound calls with members and provider offices to provide resolution to claims (i.e.: additional information requests and medication determination updates)

• Actively involved in the initiation and providing status for prior authorization, coverage determination, appeal /redetermination phone calls

• Responsible for ensuring outstanding attention to detail

• Identify root cause issues to ensure enterprise solutions and communicate findings as needed to ensure first call resolution

• Maintained customer satisfaction with forward-thinking strategies focused on addressing customer needs and resolving concerns.
• Answered customer telephone calls promptly to avoid on-hold wait times.
• Answered constant flow of customer calls with minimal wait times.
• Offered advice and assistance to customers, paying attention to special needs or wants.
• Actively listened to customers, handled concerns quickly and escalated major issues to supervisor.

• Managed incoming calls and directed to appropriate department.
• Organized paperwork such as charts and reports for office and patient needs.
• Maintained rapport with physicians, nurses and other healthcare personnel.
• Maintained current and accurate medical records for patients.
• Communicated with insurance providers to resolve denied claims and resubmitted.
• Researched CPT and ICD-9 coding discrepancies for compliance and reimbursement accuracy.
• Identified and resolved patient billing and payment issues.
• Created and maintained up-to-date patient medical records to enable tracking history and preserve consistent information.

• Used communication and problem-solving skills to resolve customer complaints and promote long-term loyalty.
• Maintained customer satisfaction with timely table check-ins to assess food and beverage needs.
• Trained staff members on use of POS system.
• Upheld high standards of professionalism when dealing with customer issues, supporting serving staff and waiting on tables.
• Performed daily administrative tasks, such as ordering supplies, processing invoices and reconciling accounts.
• Set schedules for staff by planning and designating shifts and hours.