Passionate professional with 16yrs experience in the Healthcare and Health Insurance Industry. Seeking to obtain a position with a progressive company using past work experience skills and quick learning ability to generate success and grow within the company.
Hi, I’m
Wykesha Harris
Marietta,GA
Summary
Overview
20
years of professional experience
1
Certification
Work History
United Healthcare, UHG
Provider Liaison - Strategic Initiatives
03.2022 - Current
Job overview
- Engages directly with healthcare providers or their delegates to negotiate reimbursement amounts on behalf of UHC members with Naviguard benefit.
- Research claims, reviews Out-of-Network (OON) payment history, medical bills, related documentation from providers, and summarizes information to determine best negotiation strategy to reduce or eliminate member's surprise balance billing.
- Closely track and document each negotiation, providing timely follow-up and issue closure with providers and consumers
- Collaborate with internal teams to discuss/share provider negotiation outcomes and trends for improvement initiatives.
- Outreach to members and their providers to educate on benefits and redirect OON Outpatient surgical procedures to In Network POS, to ensure members pays lowest possible out of pocket expenses.
Aetna/CVS Health
Govt. Ops. Program Manager
07.2017 - 03.2022
Job overview
- MAPD and Senior Supplemental Plans multi-carrier contracting to ready-to-sell process for Field agents, Telesales agents and Agencies (Carriers: Humana/Careplus, UHC, Aetna/Coventry, Centene/WellCare, Cigna,Anthem/BCBS, BrightHealth, Devoted, Molina Medicare, Simply, HealthSun, MMM, Solis, etc.).
- Recruit agents then assist, guide, and train on multi-carrier contracting steps
- Execute, review and process online and paper contracting requests.
- Create step by step contracting presentations.
- Act as liaison between brokers and carriers.
- Analyze, research and provide quick resolutions to all escalated contracting, certifications, and commissions issues received via email, chats and inbound calls.
- Identify and effectively communicate contracting to ready to sell updates, trends and issues in weekly meetings with Broker Managers in assigned region.
- Managed all contracting matters for Telesales division averaging 100-140 brokers (8months).
CarePlus – Humana
Field Marketing Rep - Medicare Sales
02.2017 - 07.2017
Job overview
- Plan, organize, and execute tabletop marketing events, educational events and seminars in Medicare rich communities
- Set appointments with prospects in Broward and Palm Beach County to present and sale MAPD or DSNP products based on their needs, in-home or at a designated location
- Regularly visit 13 assigned PCP offices and medical centers to discuss, strategize and plan on ways to grow practice, increase membership, and act as primary point of contact for insurance questions
- Partner with marketing and activity coordinators to conduct events and organize fun/activity day with seniors to build relations in community
- Act as a walking access center to assist prospects with social service needs and connect with vital community resources.
Aetna
CMA - Case Management Associate
08.2016 - 03.2017
Job overview
- Create authorizations for members being transferred to SNF, LTAC and, Rehab Centers under direction of Nurse and Medical Director
- Identify principle transfer reasons, facility, and member product to accurately create authorizations.
- Conduct verifications of SNF, Rehab, and LTAC scheduled admissions, urgent admissions, transfers and discharge planning needs.
- Perform maintenance and closure of open cases.
- Create and submit Appeals under direction of patient’s Physician, Nurse and Medical Director.
- Provide support to team members by answering telephone calls, taking messages, researching authorizations for facilities and assist in finding solutions to problems.
EmblemHealth
Medicare Direct Marketing Support Rep
08.2013 - 07.2015
Job overview
- Determine member’s qualifications for Managed Long-Term Care (MLTC) Plan based on their ability to perform ADLS without assistance, including schedule in home appointments for Nurse to perform assessment.
- Support Sales dept by assisting inbound callers on choosing the best MAPD plan and DSNP to meet their needs including determine eligibility, set up in-home Sales Appointments, and send plan literature.
- Facilitate and resolve customer’s Enrollment problems via internally or externally to expedite process.
- Lead in other Retention and Outbound projects including but not limited to Medicaid & Medicare New Member's Welcome Calls, Home Assessment Appointments, Providers Network & Plan Education calls, MAPD Dis-enrollment Surveys, etc.
- Successfully maintained and exceeded company’s monthly production goals.
Altegra Health Formerly Social Service Coordinators
Case Manager & Case Reviewer (Promotion)
10.2009 - 04.2013
Job overview
- Review assigned Team of Case Manager's cases to verify completeness, company and state rules/guidelines are met, and to ensure state approval.
- Provide feedback and coach Case Managers on Areas of Improvement.
- Managed 100+ monthly caseloads of Medicaid/Medicare dually eligible qualified members.
- Outreach to prescreened members nationwide to determine eligibility for Medicaid, Medicare Savings Program, and LIS – Low Income Subsidy based on state-to-state guidelines.
- Act as applicant's Authorized Representative to assist with application process and ensure approval.
- Research and obtain proofs of incomes and assets on behalf of the applicant.
- Mail completed application to sign and follow up to ensure documents are returned within a timely manner
- Maintained company’s monthly production goals and quality standards.
EmblemHealth
Cust Serv Advocate & Medicare Enrollment Processor
08.2006 - 10.2009
Job overview
- Assist with Medicare enrollment process for new GHI, HIP, & Connecticare’s members based on CMS Enrollment rules and regulations.
- Application data entry including maintaining and updating demographics.
- Effectively research and resolve beneficiary’s enrollment complaints and inquiries delegated by Customer Service Management Teams.
- Discussed benefits and claims issues with a large volume of GHI, HIP, & Connecticare’s members
- Coordinate with Enrollment, Billing, Claims, Pharmacy internally and externally to ensure services are provided to members per their plan, providers contractual agreement, and CMS regulations.
- Productively follow up on matters through intervention and/or investigation to ensure prompt resolutions.
PRECISION RESPONSE CORPORATION
Earlier Career Roles
02.2003 - 06.2006
Job overview
- Quality Assurance Specialist (Promotion)
- DirecTV Floor Team Lead (Promotion)
- DirecTV Sales Rep
Education
Keiser UniversityFort Lauderdale, FL
No Degree from Nursing
11.2008
University Overview
Keiser Career College - Pembroke PinesMiami, FL
from Medical Assistant
06.2005
University Overview
Miami Dade College - NorthMiami, FL
No Degree from Nursing
University Overview
Miami Jackson Senior High SchoolMiami, FL
High School Diploma
06.2002
University Overview
Skills
- Experienced with Health Insurance Systems: ICUE, ISET, NDB, ASD, ATV, IDX, Market Prominence, Rumba-Qcare, Info- crossings (Medicare), EPACES (NY Medicaid), MIIM, MySme, EDSS, RxWEB, RxClaim
- Proficient with Salesforce, SharePoint, Teams, WebEx, Genesys, Qfinity
- Proficient with Microsoft Office Systems
- Leadership role over 35-100 Call Center Employees
- Self-starter accustomed to working independently with little to no supervision
- Ability to maintain employee positivity and increase morale within stressful working environment
- Fast Learner with ability to multitask and drive change within high paced environment
- Interpersonal and Relationship-Building Skills
- Oral and Written Communication Skills
- Strong Analytical Skills; pay close attention to all existing details
- Strong critical thinking and problem-solving skills
- Strategic Initiatives / Strategic Plan Implementation
Certification
- Licensed 0215 Life & Health Agent, FL Dept of Insurance, 02/2017-
- Adult and Pediatric First Aid/CPR/AED, American Red Cross, 7/2020-7/2022
- Medical Assistant Certificate, Keiser Career College, 11/2004-6/2005
Timeline
Provider Liaison - Strategic Initiatives
United Healthcare, UHG
03.2022 - Current
Govt. Ops. Program Manager
Aetna/CVS Health
07.2017 - 03.2022
Field Marketing Rep - Medicare Sales
CarePlus – Humana
02.2017 - 07.2017
CMA - Case Management Associate
Aetna
08.2016 - 03.2017
Medicare Direct Marketing Support Rep
EmblemHealth
08.2013 - 07.2015
Case Manager & Case Reviewer (Promotion)
Altegra Health Formerly Social Service Coordinators
10.2009 - 04.2013
Cust Serv Advocate & Medicare Enrollment Processor
EmblemHealth
08.2006 - 10.2009
Earlier Career Roles
PRECISION RESPONSE CORPORATION
02.2003 - 06.2006
Keiser University
No Degree from Nursing
Keiser Career College - Pembroke Pines
from Medical Assistant
Miami Dade College - North
No Degree from Nursing
Miami Jackson Senior High School
High School Diploma
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