MERCY ADELSON
Pontiac
Summary
Professional representative with robust experience and strong commitment to delivering exceptional results. Effective at collaborating within teams and adapting to changing needs to ensure reliability and success. Skilled in communication, problem-solving, and customer relations, with focus on achieving impactful outcomes. Valued for proactive approach, integrity, and ability to build lasting professional relationships.
Overview
7
7
years of professional experience
1
1
Certification
Work History
Benefit Setup Rep II
CVS
09.2023 - Current
- Claims Processing & Adjudication: Ensuring benefit setups align correctly with claim processing rules to prevent rejections or incorrect payments.
- Troubleshooting Claim Issues: Investigating and resolving claim discrepancies, such as denials due to incorrect benefit configurations.
- Testing Claims Scenarios/QA: Running test claims to verify that benefit setups function as expected before implementation.
- Compliance & Auditing: Ensuring claim processing follows federal and state regulations, as well as contractual agreements.
- Analyzing Benefit Structures: Evaluating plan designs, coverage levels, and formulary setups to ensure accuracy and compliance with contractual agreements.
- Data Analysis & Problem-Solving: Identifying trends in claim rejections or processing errors, conducting root cause analysis, and implementing corrective actions.
Rep I Tech prior authorization
CVS
04.2023 - Current
- Discuss prescription drugs, insurance policies, and prior authorization forms with patients, MDO, and ETC
- Obtain prior authorization from nurse management and insurance companies
- After insurance companies deny prior authorization, appeal the decision
- Check the correctness and completeness of the accounting
Rep II Tech prior authorization
CVS
10.2022 - 04.2023
- Supporting patients who require therapy that requires pre-authorization from their insurance company using the following systems, Rx-claims, people safe, MHK, source, Microsoft, outlook, and claim to process
- Obtaining pre-authorization by either fax, electronic, or phone
- When additional information is needed we receive information by reaching out to the provider manager, medical assistant or nurse and etc
Patient Resolution
CORAM
04.2022 - 10.2022
- Enhanced customer satisfaction by efficiently resolving complex issues and implementing appropriate solutions.
- Contributed significantly towards enhancing the reputation of the company as a customer-centric organization by focusing on prompt and effective resolutions.
- Reduced case backlog by prioritizing urgent matters and delegating tasks effectively.
- Recognized as an expert in conflict resolution techniques, often consulted by colleagues on challenging cases.
Pharmacy Service Representative
CVS
09.2021 - 02.2022
- Responsible for completing daily, regular work in the pharmacy, such as answering the phone and responding to client requests;
- Data entry; record maintenance; and other clerical responsibilities
Sales Associate/Cashier/Customer Service
JCPenney
08.2019 - 06.2020
- Greeted customers
- Offered knowledge about clothing and services
- Communicated with customers over the phone
- Entered customer information into the computer
- Received and filed online orders
- Completed in-store purchases
- Handled in-store returns
- Created an inventory of products
- Cleaned around the registrars daily
- Worked in sales, selling merchandise
- Signed up customers for JCPenney credit card
- Audited and organized the whole store weekly
- Replenished merchandise
Cashier/Sales
Tim Hortons
11.2017 - 07.2019
- Responsibilities of focus on customer satisfaction
- Greet customers, take food orders, prepare, and bake food, run cash registers, and keep stores clean and sanitized
- Responsibility for proper handling and storage of food
Education
Completed coursework - dental hygienist Biology
OAKLAND COMMUNITY COLLEGE
Waterford, MI01-2026
High school diploma -
MICHIGAN GREAT LAKES VIRTUAL ACADEMY
Manistee, MI06.2019
Skills
- Customer Service
- Photoshop
- PowerPoint
- Cross-Trained
- Computer Literacy
- Microsoft Word
- Restaurant Experience
- Supervising training and leadership position training
- Fluency in Arabic
- Credit
- Client
- Fluency in English
- Fast pace
- Interpretation
- Negotiation
- Research
- Sales
- Rx claims
- People safe
- CAS
- Excel
- Outlook
- Phone
- Writing Skills
- Prior Authorization
- Computer navigation proficiency
- Microsoft Office
- Production and Quality
- Claim processing
- Sharepoint
- Data entry
- Beginner Japanese
- Beginner Korean
- Beginner French
- Analyzing
- Quality Assurance
Certification
- Certified Pharmacy Technician (CPhT) - Pharmacy Technician Certification Board (PTCB).
Timeline
Benefit Setup Rep II
CVS
09.2023 - Current
Rep I Tech prior authorization
CVS
04.2023 - Current
Rep II Tech prior authorization
CVS
10.2022 - 04.2023
Patient Resolution
CORAM
04.2022 - 10.2022
Pharmacy Service Representative
CVS
09.2021 - 02.2022
Sales Associate/Cashier/Customer Service
JCPenney
08.2019 - 06.2020
Cashier/Sales
Tim Hortons
11.2017 - 07.2019
High school diploma -
MICHIGAN GREAT LAKES VIRTUAL ACADEMY
Completed coursework - dental hygienist Biology
OAKLAND COMMUNITY COLLEGE
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