United States
Optimized care coordination workflows, supporting clinical teams and improving service delivery timelines. Managed inbound/outbound calls weekly, providing accurate and empathetic member and provider support. Researched and connected members to community resources, increasing access to essential services by identifying gaps in care. Maintained 100% compliance with quality standards through continuous training and process improvement initiatives.
Acted as primary advocate for members and providers, resolving inquiries and coordinating service requests efficiently. Achieved high First-Call Resolution rates, reducing unnecessary call transfers and improving customer satisfaction metrics. Supported cross-functional teams by providing timely updates and clear documentation, improving internal communication workflows. Maintained performance in a fast-paced remote environment, adapting quickly to workflow changes while exceeding productivity targets.
Processed high volumes of unemployment claims accurately and within strict state deadlines, ensuring regulatory compliance. Conducted in-depth investigations of contested claims and complex redeterminations, mitigating errors and improving adjudication outcomes. Managed sensitive claimant data in accordance with security protocols, maintaining zero compliance breaches. Applied active listening and de-escalation techniques to resolve emotionally charged cases, enhancing claimant satisfaction and trust.
Coordinated full authorization request process for veterans’ specialty care, improving appointment scheduling efficiency by 20%. Reviewed and processed complex prior authorizations to meet medical necessity and regulatory standards, reducing claim denials. Communicated with provider offices to obtain required records, ensuring timely and accurate processing. Maintained comprehensive tracking through CRM and medical management systems, ensuring 100% timely resolution per service standards.