Delivered exceptional member support by addressing inquiries related to claims,
billing, and coverage ensuring clarity and satisfaction throughout the process.
Conducted in depth investigation and resolution of billing concerns, meticulously
reviewing ICD (diagnosis), CPT (procedures), and HCPCS (supplies/equipment)
codes for accuracy and compliance during claim submission.
Assisted members in locating in-network healthcare providers, leveraging
knowledge of eligibility and prior authorization requirements to minimize claim
denials.
Diagnosed and resolved website and digital access issues promptly, supporting
seamless member interactions with claims portals and self service tools.
Provided timely updates on claims status interpreting Explanation of Benefits (EOB)
and Remittance Advice (RA/ERA) enhancing transparency and fostering member
trust.
Guided members through understanding and breakdown of out of pocket costs,
including copays, coinsurance, deductibles, and co payments.
Maintained accurate and up to date member records by verifying demographic,
insurance, and coverage details critical to preventing submission errors and denials.
Clarified complex authorization and referral protocols to both members and
providers, mitigating processing delays and claim rejections.
Managed prescription and medical claims end to end including scrubbing claims,
validating ICD/CPT/HCPCS coding, identifying denial reasons, and initiating
corrections or appeals.
Ensured proactive follow-up with payers for unresolved claims, submitting corrected
claims or formal appeals with supporting documentation (e.g., updated codes or
authorizations).
Handled a high daily call volume (40+), maintaining professionalism, attention to
detail, and efficiency in every interaction.
