Tabrianna Jones
Molina Healthcare
Florissant
11
years of professional experience
Utilization Management Representative supporting medical terminology, claims processing, and insurance regulations to review documentation, verify member information, and help move cases toward accurate decisions. Builds on claim intake, investigation, and careful follow-up experience to manage 21-35 provider follow-up requests per week across phone, email, letters, and in-person communication while keeping records complete. Brings calm customer communication and steady resubmission support to help resolve denied or incomplete cases.
Work History
Claims Representative
5 Years 2 Months- Reviewed claim files weekly for accuracy, completeness, and readiness before approval.
- Handle 50 or more claims daily by prioritizing submissions, applying best practices, and keeping work moving.
- Provide timely claim status updates and resolve customer questions with clear, professional communication.
- Collaborate with cross-functional teams to investigate complex claims and move difficult cases toward resolution.
- Prepare insurance claim forms, verify coverage details, and resubmit denied claims after careful edits.
Member Service Representative
2 Years 7 Months- Reviewed member eligibility details and pharmacy benefits to answer coverage questions accurately.
- Explained plan requirements, claim outcomes, and next steps in clear language during member calls.
- Documented call details, claim notes, and follow-up actions in accordance with internal procedures.
- Applied claim review guidelines to identify missing information and support accurate processing decisions.
- Used active listening to identify the root cause of member questions and reduce repeat contacts.
- Supported coverage determination by checking eligibility details and confirming required documentation.
- Entered member data carefully to maintain accurate records across service and billing workflows.
- Tracked claim status updates and followed up on unresolved cases until completion.
- Handled member concerns calmly while maintaining professionalism during high-volume service periods.
- Applied policy knowledge to explain coverage limitations and support accurate claim outcomes.
Shift Manager
3 Months- Tracked task completions daily to keep staff productive during busy store periods.
- Trained and mentored new hires to strengthen team performance and ramp-up consistency.
- Kept employees focused on assigned work to support daily customer and business needs.
- Supervised front-line staff and monitored quality compliance with company standards for food and service.
- Coordinated breaks and shift coverage with team members to meet state labor requirements.
Customer Service Manager
1 Year 11 Months- Coached associates on customer service techniques and training and mentoring to strengthen day-to-day performance.
- Tracked customer concerns, maintained accurate records, and improved follow-up through consistent documentation review.
- Partnered with upper management to refine service processes and support structures across the store.
- Handled pricing questions, inventory availability, and order updates with clear communication and professionalism.
- Managed employee schedules, performance feedback, and team priorities to support daily workflow and coverage.
Education
Parkway West High School
Skills
Claims processing
Claims investigation
Coverage determination
Insurance claims review
Insurance coverage verification
Eligibility determination
Claim amount calculations
Documentation review
Customer service
Interpersonal communication
Active listening
Conflict resolution
Telephone etiquette
Team supervision
Workflow management
Training and mentoring
Time management
Organizational skills
Appeals management
Case closure reporting
Accomplishments
Top customer service agent
Overall adherence time on call meeting goals monthly
Timeline
Shift Manager
CVS Pharmacy
11.2021 - 02.2022Read More
Claims Representative
Molina Healthcare
08.2021 - CurrentRead More
Member Service Representative
Express Scripts Pharmacy
01.2020 - 08.2022Read More
Customer Service Manager
Walmart
04.2016 - 03.2018Read More
Parkway West High School
Parkway West High School
Read More