Charmaine Harris

Charmaine Williams 5113 Autumn Oak Dr. Charlotte NC, 28269 -- EXPERIENCE: Job Title: Beneficiary Service Representative Company Name: Humana Government Business Start Date: 10/02/2017 End Date: Presently Employed Responsibilities and Achievements Receive telephone, written, fax, and e-mail inquiries concerning TRICARE eligibility, benefits determinations, and claims adjudication questions or billing problems. Apply appropriate provisions of TRICARE regulations, interpretations, and procedural directives in making determinations on eligibility and benefits to determine appropriate responses to inquiries. Obtain and analyze claims data to determine specific problem area including external communication to obtain data. Complete research and provide final resolution to inquiries within contractual requirements. Communicate with inquirer to determine appropriate authorization or referral of services. Submit claims for adjudication, correction, payment, or review as appropriate. Educate providers on billing requirements of TRICARE to reduce claim problems. Deal tactfully with people in a wide variety of situations to convey a favorable corporate image. Respond to inquirer using various forms of communication (written letter, telephone, web, or email) within time frames to exceed contractual standards. Collect and record data for Customer Service records and computer analysis. Inform supervisory staff of system problems when identified, researching problems to provide backup data and examples when needed. Job Title: Pharmacy Customer Service Specialist Company: Express Scripts Start Date: 08/01/2016 End Date: 10/02/2017 Responsibilities and Achievements (Work From Home) Responsible for verifying drug coverages, benefit types, eligibility dates, and claim payment / statuses for providers, billing. Estimate member's out of pocket expenses for select procedures or services and explain copayments. Process refills, renewal requests, mail orders, and enroll members into automatic worry-free fill program Reprocess rejected pharmacy claims, prior authorizations, and appeals Ability to meet established performance goals in the areas of efficiency, call quality, customer satisfaction, first call resolution, adherence, and attendance Analyzes and manually processes complex or technically difficult general pharmacy claims by investigating and gathering information to determine the exposure on the claim; manages claims through well-developed action plans to an appropriate and timely resolution. Resolves claims within evaluation and negotiates settlement of claims within designated authority. Calculates and pays benefits due; approves and makes timely claim payments and adjustments. EDUCATION: ECPI University- Bachelor’s Degree Healthcare Administration