Roxeanne Santos

Customer Service Representative – DME Service Solutions BPO

2023 – Present (Remote)

Summary:
Dedicated Customer Service Representative specializing in durable medical equipment (DME) and diabetic testing supplies for U.S.-based pharmacies, including North Coast Medical Supplies and Edgepark Pharmacy. Experienced in intake creation, benefits verification, prescription follow‑up, and referral/data entry. Provides accurate, compassionate, and efficient service to members and healthcare providers.

Key Responsibilities:

• Handles inbound and outbound calls from members requesting diabetic testing supplies, ensuring accurate intake creation and timely order processing.
• Conducts benefits and eligibility checks to confirm coverage for glucose monitors, test strips, lancets, and other diabetic supplies.
• Performs “doc chase” by contacting providers’ offices to obtain required prescriptions, CMN/SMN forms, chart notes, and other medical documentation to support DME orders.
• Collaborates with physicians, clinical staff, and office administrators to secure missing paperwork and ensure compliance with insurance and Medicare requirements.
• Processes referral and data entry tasks, including submissions received from sales agents or parachute referrals, ensuring accuracy and completeness.
• Updates member records, verifies demographic and insurance information, and documents all interactions per HIPAA and internal quality standards.
• Supports pharmacy workflow by reviewing order status, shipment timelines, prior documentation issues, and resupply schedules for diabetic equipment.
• Provides knowledgeable and empathetic service, educating callers on order processes, documentation needs, and timelines.
• Meets performance metrics for call handling, accuracy, productivity, and customer satisfaction in a remote, fast‑paced environment.

Skills:

• Diabetic testing supplies (DME) intake
• Benefits & eligibility verification
• Inbound & outbound call handling
• Prescription and medical records follow‑up (“doc chase”)
• Referral & data entry (including parachute referrals)
• Knowledge of Medicare and commercial insurance requirements
• Provider communication & documentation retrieval
• HIPAA compliance
• Strong attention to detail and multitasking
• Remote work efficiency & time management

Customer Service Representative (Provider Services)

UnitedHealthcare (2016-2023)

Summary:
Experienced Customer Service Representative specializing in provider services within UnitedHealthcare. Skilled in resolving complex provider inquiries, supporting claims and appeals processes, verifying member benefits and eligibility, and creating prior authorizations in compliance with company policies and CMS guidelines. Consistently recognized for accuracy, professionalism, and exceptional service delivery.

Key Responsibilities:

• Provided high‑level support to healthcare providers regarding claim submissions, status updates, billing issues, and appeals processes.
• Resolved escalated provider concerns by researching claims, reviewing denial reasons, and ensuring appropriate documentation and follow‑through.
• Verified member eligibility, benefit coverage details, cost‑share amounts, and plan restrictions across multiple UHC platforms.
• Processed and created prior authorization requests for various medical services, medications, and procedures while maintaining adherence to clinical and regulatory requirements.
• Educated providers on UnitedHealthcare policies, claim coding requirements, timelines, and appeal rights.
• Coordinated with internal departments (claims, clinical review, appeals, utilization management) to resolve complex provider cases.
• Documented all interactions accurately and thoroughly in accordance with UHC quality and compliance standards.
• Achieved or exceeded performance metrics, including call quality, accuracy, productivity, and customer satisfaction targets.
• Maintained strict confidentiality and compliance with HIPAA guidelines.
• Provided empathetic, professional service in fast‑paced, high-volume environments.

Skills:

• Provider services support
• Claims & appeals resolution
• Benefits & eligibility verification
• Prior authorization processing
• Medical terminology & insurance knowledge
• Issue resolution & multitasking
• Strong written and verbal communication
• HIPAA compliance & data accuracy