Vanetta Johnson

• Processed complex Medicare Part D coverage determinations.
• Utilized RxCLAIM and AS400 systems to review, document, and track authorization requests
• Collaborated with providers, pharmacists, and healthcare teams to secure clinical documentation for prior authorization requests.
• Ensured accuracy and regulatory compliance while managing high-volume case workloads.
• Provided timely support to members, providers, and pharmacies on coverage and authorization inquiries.
• Researched formulary requirements, prior authorization criteria, and utilization management guidelines.
• Researched formulary tiers, prior authorization requirements, and utilization management criteria.

• Facilitated the end-to-end prior authorization process, ensuring efficient

management of up to 60 faxes and 30 phone inquiries daily from healthcare

professionals and pharmacies regarding medication coverage.

• Conducted comprehensive eligibility and compliance verification per

authorization requirements, proactively collaborating with physicians to gather

necessary clinical data for smooth prior authorization submissions.

• Closely monitored pending cases, ensuring timely follow-up on documentation

essential for successful outcomes, which enhanced approval rates by 20%.

• Utilized departmental guidelines to conduct in-depth research on medication

inquiries, accurately guiding clients on coverage options.

• Fostered strong relationships with clients, enhancing satisfaction through timely

and thorough follow-up on inquiries and concerns.

• Applied data-driven decision-making strategies to optimize workflows, improving

operational efficiency within the prior authorization department.

• Handled high-volume inbound calls regarding claims status, benefits, billing, and policy inquiries.

• Resolved customer concerns while delivering exceptional service and support

• Educated customers regarding billing procedures, payments, and policy services.

• Reviewed policy language and explained benefits, coverage provisions, and account information.

• Protected confidential customer information while maintaining compliance standards.

• Assisted customers with inquiries regarding benefits, payments, case information, and program services.
• Maintained confidentiality of sensitive consumer information.
• Documented interactions accurately within applicable systems.
• Resolved customer concerns and facilitated referrals according to established guidelines.
• Delivered exceptional customer service in a high-volume call center environment

• Assisted policyholders with questions regarding policies, claims, and benefits.
• Reviewed and explained policy coverage and claim information.
• Served as liaison between policyholders, claims adjusters, and internal departments.
• Resolved customer issues and maintained strong client relationships.
• Managed sensitive situations with professionalism and attention to detail

• Educated clients on insurance products and services, empowering informed decision-making.
• Provided clear and accurate information about insurance products.
• Resolved customer complaints and issues effectively.