Michael

Serve as primary contact for Medicaid, Medicare, and QHP members, resolving 50+ daily inquiries via phone, email, and live chat with 95% first-contact resolution.. Verify member eligibility, explain benefits, process prior authorizations, and assist with PCP selection and referrals.. Handle claims inquiries and reimbursement requests, investigating discrepancies, denied services, and billing issues in coordination with internal claims teams.. Document all member interactions in Salesforce CRM while maintaining full HIPAA compliance for protected health information (PHI).. Educate members on preventive care, prescription drug coverage, and plan renewals, increasing retention by 15%.. Collaborate with clinical and provider relations teams to escalate complex medical necessity cases.

Assisted homeowners with service contract coverage, claims processing, and technician dispatch for HVAC, plumbing, and electrical systems.. Verified coverage eligibility, explained policy limits and service fees, and resolved billing disputes.. Documented all customer interactions in Salesforce CRM, ensuring accurate claim histories.. Identified recurring coverage gaps and reported trends to management, improving service response times.