Results-driven Healthcare Customer Service and Administrative Professional with over a year of experience supporting multiple Lines of Business (LOBs) within the healthcare industry. Demonstrated ability to manage complex member and provider inquiries related to claims, benefits, eligibility, and appeals while maintaining high standards of accuracy, compliance, and customer satisfaction. Recognized for strong problem-solving abilities and attention to detail, leading to a promotion as a Subject Matter Expert (SME) within the same company after one year of consistent performance and leadership. Experienced in handling escalations, providing floor support, coaching tea-----------mbers, and serving as a resource for process updates and healthcare policies. Adept at navigating multiple healthcare systems to verify patient information, resolve issues efficiently, and ensure a positive member experience.
Healthcare Tools and Systems Used
-Electronic Health Records (EHR) systems
-Customer Relationship Management (CRM) platforms
-Claims Processing Systems
-Member Eligibility and Benefits Verification Portals
-Provider Portals
-HIPAA-compliant databases
-Medicare and Medicaid verification systems
-Avaya or Genesys phone systems
-Microsoft Outlook
-Microsoft Excel
-Microsoft Teams
-Knowledge Base/Reference Tools
-Internal Healthcare Documentation Systems
Typical Information Verified:
-Member eligibility and enrollment status
-Policy effective dates
-Benefits and coverage details
-Claims status and payment information
-Prior authorization requirements
-Provider network participation
-Demographic information
-Coordination of benefits
-Appeal and grievance status
Soft Skills
-Excellent Communication Skills
-Active Listening
-Customer Service Excellence
-Empathy and Compassion
-Conflict Resolution
-Problem-Solving
-Critical Thinking
-Adaptability
-Time Management
-Attention to Detail
-Team Collaboration
-Leadership and Mentoring
-Decision-Making
-Professionalism
-Multitasking in Fast-Paced Environments
-Accountability
-Coaching and Training Support
Hard Skills
-Healthcare Claims Processing
-Benefits and Eligibility Verification
-Appeals and Grievance Handling
-Patient Information Verification
-HIPAA Compliance
-Medical Terminology
-Healthcare Policy Interpretation
-Escalation Management
-Root Cause Analysis
-Quality Assurance Support
-Documentation and Case Management
-Data Entry and Data Validation
-CRM and Healthcare Systems Navigation
-Microsoft Excel Reporting
-Performance Monitoring
-Process Improvement
-Call Handling and Call Documentation
-Subject Matter Expert (SME) Support Functions
-Member and Provider Services
-Regulatory Compliance
