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Skills

  • Customer service
  • Customer service in healthcare
  • Network expansion with pharmacies
  • Handling appeals and contested cases
  • Claims adjudication
  • Data-driven decision making
  • Call center operations in PBM
  • First-Call Resolution Enhancement
  • Relationship development
  • Business operations

Work Experiences

  • Achieved service level targets.
  • Achieved results within 5 months.
  • Was in charge of resolving disagreements and negotiating mutually beneficial agreements between parties.
  • Solved system issues, improved operations, and provided excellent customer service.
  • Had an excellent attendance record and was always on time for work.
  • Recommend successful approaches to Prescription Benefit Specialist for resolving salary and classification complaints.
  • Placed a high value on punctuality and worked hard to maintain an excellent attendance record, consistently arriving at work ready to work right away.
  • Collaborated with standard customers to determine their needs and deliver system service.
  • Achieved this within 18 months.
  • Assessed new market trends in prescription benefits and provided insights that shaped 17 key strategic initiatives.

Summaries

  • Achieved results over 16 months.
  • Within Miscellaneous, senior Prescription Benefit Specialist and outstanding performer in strategic planning and budget management.
  • Overall morale and productivity are boosted by experience in policy development and staff management procedures.
  • Creative Prescription Benefit Specialist.
  • Bolstered approval rates for members.
  • Achieved accuracy rates exceeding 48%.
  • Conducted diligent review and correction of claims data.
  • Collaborative Prescription Benefit Specialist known for enhancing formulary understanding by developing training materials that lowered call center support requests by 31% %.
  • Adhered to metric.
  • Customer-focused problem solver with excellent mediation skills, resolving billing disputes and ensuring the recovery of over $8 in denied claims within tight deadlines.

Accomplishments

  • Developed a new appeals process that successfully overturned 59% of denied claims, generating increased member satisfaction and preserving $16 in revenue.
  • Created and maintained a formulary system that improved claims adjudication accuracy, reducing processing errors by 53%.
  • Led redesign efforts for customer service scripts, improving member understanding of prescription benefits and reducing call escalations by 49%.
  • Overhauled the prior authorization process, reducing approval timeframes by 79% and enhancing overall service delivery to affected members.
  • Reduced cost discrepancies in prescription drug claims by 66% by providing real-time support and clarification to pharmacy networks.
  • Developed and delivered training sessions on best practices for formulary management, improving team adherence to standards and reducing claim errors by 18%.
  • Monitored healthcare policy changes and adapted processes accordingly, ensuring ongoing compliance with standard, preventing potential penalties.
  • Collaborated with cross-functional teams during system upgrades to ensure all prescription benefit functions remained operational with minimal downtime.
  • Administered benefit plan modifications for ServiceNow, improving formulary compliance and communication with members by 54%.
  • Used Microsoft Excel to develop inventory tracking spreadsheets.

Affiliations

  • Society of Women Engineers
  • American Academy of Professional Coders (AAPC)
  • American Society of Health-System Pharmacists (ASHP)
  • Association for Supply Chain Management (APICS)
  • Association of Information Technology Professionals
  • Healthcare Financial Management Association (HFMA)
  • Healthcare Compliance Association (HCCA)
  • Pharmacy Technician Certification Board (PTCB)
  • Society of Actuaries - Health Section
  • National Alliance of State Pharmacy Associations (NASPA)

Certifications

  • Certified Pharmacy Technician (CPhT) - Summit Group
  • Advanced Medicare Certification for Benefits Specialist - Northwind
  • Certification in Call Center Customer Service Skills - Brightline
  • Certified in HIPAA Compliance (CHC) - Summit Group
  • Certified Claims Specialist (CCS) - Vantage
  • Certified Professional in Healthcare Billing and Coding - Vantage
  • Certificate in Health Benefits and Wellness (CHBW) - Harbor & Co.
  • First Aid/CPR Certified
  • Certified Professional in Commercial Insurance (CPCI) - Brightline
  • Healthcare Compliance Certification (CHC) - Lakeside Partners

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