Charmaine Patterson
Pulaski
Summary
Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.
Overview
7
7
years of professional experience
Work History
Insurance Claims Representative
Jacobson Group/WPS Health Insurance
11.2023 - 02.2024
- Responsible for providing immediate support to answer provider inquiries on behalf of sponsors and beneficiaries who are enrolled in Tricare, a health care program of the United States Department of Defense Military Health System that provides healthcare coverage and benefits for military personnel of those in the U.S. Armed Forces, military retirees and active duty family members.
- Assisted providers by informing of claim status, location and reject reason of claims. Ensured that revenue, procedure, and type of bill codes were accurately listed and that correct claim form type was submitted to avoid billing errors.
- Followed resources and learning material to communicate accurate and updated details relating to processing of claims, timely filing, appeal and authorization process.
- Reprocessed, adjusted, and initiated formal and informal recoupments and advised of case information to providers relating to offset claims.
- Informed providers of application process to become certified/in-network; assisted provider with becoming registered and utilizing provider portal .
- Utilized Onbase to locate, attach, and fax documents such as medical records, provider certification correspondence, copies of letters and EOBs
- Performed reissuing and stop payments of checks; informed of check details such as payment amounts, issued and clear dates, payee information, and initiated fee reviews if allowed amount of claims were calculated incorrectly.
Healthcare Representative
Faneuil/LA Care Health Plan
11.2022 - 09.2023
- Delivered exceptional customer service to every member by leveraging extensive knowledge of plans, benefits, prior authorization process, explanation of coverage and created welcoming, positive experiences.
- Adhered to company policies,procedures and scripts to consistently achieve call-time and quality standards.
- Collaborated with Pharmacy resolution specialists regarding drug coverage, formularies, and prescription tiers
- Coordinated and escalated Managed Long Term Service and Support (MLTSS) requests to arrange services for members to receive In-home supportive services, Nursing home care, and access to community- based services and programs.
- Faxed Service Authorization requests and eligibility verification forms to medical groups and provider offices to prevent delay in processing and service.
- Facilitated information to members pertaining to Medi-cal & Medicare eligibility and renewal process by utilizing external resources provided by Health Care Options (HCO), Department of Social Services (DPSS), and Department of Health Care Services (DHCS)
Member Service Representative
BCforward/Anthem & Reqroute/Ambetterhealth- Temp
10.2021 - 11.2022
- Mailed member material such as Welcome packets, ID cards, Explanation of coverage, and Summary of benefits.
- Assisted members with locating in-network providers, updating PCP information, viewing authorizations in member portal and determining balances in rewards programs.
- Provided deductible, copay, and coinsurance information for procedures and medical services. Authorized premium payments, assessed billing and invoice concerns; performed payment tracers and resolved past due account balances.
- Liaised with the Health Insurance Marketplace to assist members with determining eligibility for lower costs towards monthly premiums based on their income.
- Internally routed requests for reinstatement/ cancellation of coverage to Enrollment services; Thoroughly documented and escalated complaints to Grievance unit.
Customer Care Representative
MTM
09.2016 - 05.2021
- Scheduled, modified, and cancelled member's transportation reservations for medical appointments, outpatient surgeries, hospital discharges, etc.
- Consulted/ followed up with transportation providers to obtain driver information, vehicle type, vendor availability and contractual agreements.
- Arranged and coordinated paratransit and MTA reservations for members located in U.S. cities with high transit ridership.
- Meticulously handled higher level of care reservations requiring BLS and ALS ambulance, L2K or Legal 2000;
- Assisted peers with healthplan protocols, training updates, and system functions. Handled escalated calls fairly and reasonably for the best interest of members and ensured that issues were corrected and resolved at the right level.
Education
Bachelor of Science - Business Administration And Data Analytics
Liberty University
Lynchburg12.2024
Associates of Applied Science - General Studies
New River Community College
Dublin, VA05.2012
Skills
- 10-Key Touch
- Policy and Procedure Adherence
- Productivity Performance
- CRM Documentation
- Medical Terminology
- Scheduling and Coordinating
- Conflict resolution
- Microsoft Office and Outlook
Timeline
Insurance Claims Representative
Jacobson Group/WPS Health Insurance
11.2023 - 02.2024
Healthcare Representative
Faneuil/LA Care Health Plan
11.2022 - 09.2023
Member Service Representative
BCforward/Anthem & Reqroute/Ambetterhealth- Temp
10.2021 - 11.2022
Customer Care Representative
MTM
09.2016 - 05.2021
Bachelor of Science - Business Administration And Data Analytics
Liberty University
Associates of Applied Science - General Studies
New River Community College
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