PHYLLIS L CLARK

Assesses and researches routine member and/or provider inquiries, requests and/or concerns to determines causes, and initiates corrective actions to other service or technical departments for follow up as needed.

Mitigates and prevents complaints from being escalated to resolve in initial contact. Serves as the front-line resolution advocate on various member and/or provider inquiries, requests, or concerns.

Provides support on various member or provider issues to ensure customers receive highquality service. Maintains performance and quality standards based on established contact center metrics.

Maintains performance and quality standards based on established contact center metrics.

Provides customer service in a high pace contact center environment over the phone

Documents all member or provider information and communications for quality and performance tracking through the Customer Relationship Management (CRM) applications. Remains up-to-date and adheres to quality standards, regulations, and all other policies to ensure quality, consistency, and compliance.

Provides expertise in resolving multiple inquiries, requests and/or concern across all areas of responsibilities.

Provide member resolution by researching, analyzing, and documenting inquiries regarding program eligibility; answer application and service questions regarding the programs and services to maintain and attract membership; conduct follow-up calls reminding members to return recertification applications, and request missing documentation if warranted.
Develop and maintain relationships with existing members by providing guidance and assistance through the recertification process; demonstrate passion for members by identifying unfulfilled needs and providing necessary education and assistance to promote the value and benefits offered by the Plan; modify delivery skills accordingly to overcome objections and retain members; identify solutions to issues and concerns.
Complete all required paperwork and documentation necessary to complete the application process; track and input actions taken during the recertification process to ensure all member accounts correctly reflect activities performed.
Input, update, and create member information on databases to maintain customer accounts; utilize computer systems to perform administrative functions.

• Lead Trainer of new employees during onboarding process within the department
• Liaison to providers and staff during working processes
• Responsible for the collection of medical records, appropriate clinical documents delivery to specialist offices, and uploading documents into electronic medical record platform
• Manage team members workloads and assign priority work within the department
• Coordinate the scheduling of specialist appointments and/or diagnostic orders as needed

• Updated patient information and making changes in electronic medical record platform
• Scheduled appointments within electronic medical records platform
• Communicated referral & authorization information to patients
• Obtained authorization (when required) for all third-party requests
• Requested medical records, submitting appropriate clinical documents to specialist offices, and uploading documents into electronic medical record platform
• Assembled information concerning patients’ clinical background and referral needs
• Scheduled specialist appointments and/or diagnostic orders as needed
• Managed access to and information in multiple payer portals
• Worked in multiple electronic systems as needed

• Performed inbound/outbound calls to providers to gather required information.
• Referred cases as needed for review to pre-authorization nurse.
• Resolved customer inquiries including, data processing and providing status updates.
• Ability to work independently and unsupervised maintaining a superior work ethic.
• Compiled with HIPAA Privacy and Security Regulations handling patient information.
• Prioritized work load and maintained an organized work space.

• Received phone calls from providers and/or their designee to coordinate patient services
• Wrote, faxed and/or mailed correspondence to patients and their providers regarding approval/denial of medical services
• Responded to requests for authorization of services submitted via phone, fax and mail according to Molina operational timeframes.
• Contacted physician offices according to Department guidelines to request missing information from authorization requests or for additional information as requested by the Medical Director.
• Reviewed claim requests and reconciled services requested vs. services rendered before being approved for payment

• Supported the Provider Relations Field Reps to resolve claims and payment issues. Answers incoming telephone inquiries from Providers and assist with problem resolution of issues.
• Provided root cause analysis of Health Services issues.
• Reviewed and process incoming and outgoing paperwork, including directory updates, provider credentialing applications, contract maintenance forms and other related forms.
• Completed address change requests, provider panel closures, provider terminations and office support.
• Assisted with assigned projects and performed related duties as required.

• Answered calls for the Illinois State Toll way Authority
• Investigated and resolved customer inquiries and complaints in a timely matter
• Spoke with attorneys/clients regarding all stages of the Chapter 7/13 bankruptcy process

• Effectively resolved member issues to member satisfaction
• Collaborated with Sales Representatives to resolve customer concerns
• Communicated by phone and in person in accordance with corporate policy and procedure
• Directed calls to appropriate individuals and departments