Jensine Pryor

• Handled member complaint submissions while maintaining adherence to plan guidelines and organizational policies.
• Processed appeal requests in alignment with organizational policies and client agreements.
• Created/launched cases to complete or transfer to designated sites for review
• Processed determination correspondence for members, providers, and authorized representatives.
• Assessed claims to determine suitability for reprocessing.
• Completed work under company quality and production standards
• Communicated through email with other departments as well as peers and leaders
• Ensured accurate upload of assigned case files.
• Completed company trainings promptly to stay updated on role requirements.

Member Services Representative (January 2020-July 2020)

• Managed inbound call flow, directing callers as needed.
• Updated demographic records including contact details and primary provider information.
• Processed requests for insurance and rewards cards.
• Performed health risk assessments to evaluate member well-being.
• Coordinated communications between members and external parties.
• Discussed eligibility and benefit information for members.
• Recorded grievances submitted by members.
• Faxed temporary insurance cards to pharmacy and doctor's office.
• Provided members phone numbers to different departments as needed.
• Offered survey after each call for service evaluation.

Claims Representative/Provider Services Representative (July 2020-2021)

• Handled inbound calls efficiently, transferring them when required.
• Provided complete payment details for claims to providers and third-party billers.
• Delivered denial details with counteraction strategies, including reconsideration, correction, appeal, and return requests.
• Provided status on appeals submitted for review.
• Discussed member eligibility information.
• Ensured accurate status reports for inpatient and outpatient authorizations.
• Requested check tracers for lost or delayed payments.
• Provided or requested EOB/Negative Balance reports or appeal denial letters.
• Reviewed and confirmed provider contractual agreements.
• Delivered required details to assigned Provider Relations representative for provider assistance.
• Directed emails to Provider Relations according to situations on behalf of providers.
• Delivered detailed member coverage data categorized by state systems.
• Provided third-party billers and providers numbers to different departments as needed
• Offered survey after each call for service evaluation.

• Facilitated patient check-in for procedures and office visits.
• Accepted co-pays and account payments from patients.
• Handled inbound and outbound calls efficiently transferring when necessary.
• Scheduled, cancelled and rescheduled office appointments for patients in office as well as referrals to other providers.
• Prepared super bill paperwork for billing processing.
• Tracked office patient visit statistics by provider on a monthly basis.
• Handled office phone voicemails efficiently.
• Updated patient records to ensure accuracy of medication lists and demographics.
• Performed end-of-day cash box sign-off alongside office manager.
• Drafted front sheets for future patient charts.
• Accepted samples to take back to lab for review.
• Maintained clean environment as well as organized desk.

• Managed incoming calls transferring when necessary.
• Performed donor assessments including collecting vitals and conducting finger stick tests.
• Organized and filed donor charts efficiently.
• Applied payments to donor cards.
• Created/updated donor demographics in system.
• Trained new hires in reception area.
• Conducted yearly instructional sessions for veteran employees in reception.
• Kept reception area tidy and organized.
• Completed opening and closing duties as needed.

• Handled inbound and outbound calls promptly transferring when necessary.
• Organized patient charts for next day's appointments.
• Ensured charts were filed accurately by day's end.
• Recorded and managed payment records with accuracy.
• Arranged x-rays to ensure readiness for use by directing chiropractor.
• Processed x-ray imaging onto discs for patient accessibility.
• Streamlined patient check-in and check-out procedures.
• Handled upkeep and orderliness of main greeting space.
• Faxed and received files between medical offices and hospitals.
• Arranged medical consultations at multiple doctor clinics for patients.
• Assisted with training program for incoming reception supervisor.

• Checked out customers.
• Handled customer returns.
• Sorted and organized sale items for optimal floor display.
• Handled and redirected incoming telephone calls.
• Processed customer product returns efficiently.
• Kept front space clean through regular trash removal and floor maintenance.