Heather J. Tolen
St. Louis
Summary
Dedicated senior professional with several years of experience in providing superb customer service. Expert in establishing rapport by listening to customers and understanding specific needs. Manage consistent one-call resolution to offer prompt and streamlined service.
Overview
20
20
years of professional experience
Work History
Senior Customer Service Representative
United Healthcare Group
10.2022 - Current
- Handle escalated calls, resolving more complex customer issues in a one and done manner.
- Answer incoming phone calls from customers and identify the type of assistance the customer needs (i.e. benefit and eligibility, billing and payments, authorizations for treatment and explanation of benefits (EOBs).
- Ask appropriate questions and listen actively to identify specific questions or issues while documenting required information in computer systems.
- Intervene with care providers (doctor's offices) on behalf of the customer to assist with appointment scheduling or connections with internal specialists for assistance when needed.
- Assist customers in navigating UnitedHealth Group websites and encourage and reassure them to become self-sufficient.
- Own problem through to resolution on behalf of the customer in real time or through comprehensive and timely follow-up with the member.
- Research complex issues across multiple databases and work with support resources to resolve customer issues and/or partner with others to resolve escalated issues.
Reimbursement and Eligibility Lead
Express Scripts
St. Louis
10.2014 - 08.2022
- Managed outbound telephone calls and written inquiries from pharmacists and doctors regarding prior authorization by screening and reviewing requests based on benefit plan.
- Obtained, interpreted, and submitted clinical documentation to the specific services requiring prior authorization.
- Lead problem solving and coordination effort.
- Performed research and resolve problems to help investigate denied claims.
- Communicated with insurance company personnel and providers representatives.
- Experienced in handling Medicaid and Medicare benefits.
- Updated provider practitioners with Claim payments.
- Provided analytical support for reimbursement to management and facilities.
- Assisted customers via telephone inquiries related to their specific claim status or general questions about the company's services.
- Applied knowledge of coding systems such as CPT-4 and HCPCS codes for proper reimbursement.
- Processed a high volume of incoming claims in accordance with established policies and procedures.
- Documented decisions on each claim based on research findings and applicable benefit plans.
- Resolved complex issues associated with denied or underpaid claims through negotiation with payers.
- Analyzed and evaluated claim forms, medical reports, bills, and other documents to ensure accuracy of data.
Customer Service Representative
Convergys
Hazelwood
01.2012 - 01.2014
- Handled inbound and outbound calls per day for the purpose of selling basic products and services.
- Responsible for achieving specific performance targets including quality, sales, and call handling.
- Diagnosed and provided troubleshooting for different hardware and software configurations with multiple types of equipment. Analyzed installation and configuration issues.
- Dispatched service technicians as needed to service to and handle all administrative duties to get the service orders opened and invoiced.
- Responsible for identifying and resolving potential work quality issues to resolve customer satisfaction.
- Assisted efforts to educate agent on the latest products and applications to achieve high quality service.
- Assisted with training, monitoring, and coaching to agents.
Customer Service Representative
Walmart Stores Inc.
St. Louis
01.2005 - 01.2011
- Provided effective and efficient front-end sales and services to store customers.
- Processed register transactions for customer sales and returns.
- Responsible for preparing daily balance sheet of transactions.
- Participated in company outreach programs and organizations supported by the Company.
Education
Pharmacy Technician Certification -
Everest College
St. Louis, MO01.2012
Skills
- Leadership
- Quick-base
- Google for Business
- SalesForcecom
- SAS
- Microsoft Office
- Proficient in Mac
- Google applications
- Medical Terminology
- CPT coding
- ICD-10 coding
- Attention to detail
- Insurance verification
- Problem solving
- Billing procedures
- Claims processing
Additional Credentials
Leadership, Quick-base, Google for Business, SalesForce.com, SAS, Microsoft Office, Cvent, Proficient in Mac and Google applications (Sheets, Slides, and Docs), Medical Terminology, CPT and ICD-10 coding, Mentor, Everest College for Pharmacy Students, Everest College Presidential Award
Timeline
Senior Customer Service Representative
United Healthcare Group
10.2022 - Current
Reimbursement and Eligibility Lead
Express Scripts
10.2014 - 08.2022
Customer Service Representative
Convergys
01.2012 - 01.2014
Customer Service Representative
Walmart Stores Inc.
01.2005 - 01.2011
Pharmacy Technician Certification -
Everest College