Tekila Flakes has over 10 years of experience in customer service roles within the health care industry. She currently works as a Clinical Claims Review Specialist at Humana, where she reviews inpatient claims and determines whether clinical review is required. Previously, she held roles such as Referral Intake Specialist and Claims Customer Service Representative at various companies. Tekila has a high school diploma and an Associate's degree, with additional certification in health care services expected to complete soon. She is skilled in areas like customer service, data entry, Microsoft Office, and various health insurance systems.

1. Tekila Flakes Justmetekila@gmail.com
Health Care Professional 727-692-9438
Saint Petersburg, FL
Summary
I am a dynamic customer service professional with 5+ years of experience in health care industry committed
to providing great customer service, with the ability to build positive relationships with fellow associates and
beneficiaries. I am an attentive listener who solves problems efficiently and effectively. I have lead projects
with strong analytical skills, while being detail-oriented and having excellent organizational and time
management skills. I possess excellent communication skills, team building skills and I am able convey
messages effectively.
Education, Training and Skills
Lakewood High School, Saint Petersburg, FL
High School Diploma- May 2005
Saint Petersburg College, Saint Petersburg, FL
Associates of Arts Degree 2012
Certificate in Health Care Services: Expected completion date July 2017
Skill Name Skill Level Last Used/Experience
Customer Service and Escalations Expert Currently Used/ 8 years
Data Entry and Records Management Expert Currently Used/8 years
Microsoft Word and Excel Intermediate Currently Used/10 years
Work Experience
- Over 10 years customer service experience
- 4 years of Medicare and Medicaid Insurance experience
- 1.5 years of leadership experience
Humana, Work at Home
Clinical Claims Review Specialist 12/01/2015-Present
As a clinical Claims Review Specialist, I review inpatient retro claims and decide whether clinical review is
required. I use process flows to build authorizations and determine correct status such as denied, approved or
pended. I also help to mark-up the process flow. My minimum quota is 44 claims per day. I also have a
quality minimum of 97%.
 Process notifications, authorizations, referrals and claims not requiring clinical review
 Route cases needing clinical follow-up to nurses queue
 Make outbound phone calls to complete authorization process and request clinical
 Use medical terminology and ICD-9 and ICD-10 codes
o Systems used: CGX, MTV, CAS, MACESS, CCP2, GCP, Mentor, MRM

2. Humana at Home, Saint Petersburg, FL
Referral Intake Specialist 06/01/2014-12/01/2015
Referral Specialist 12/2013-06/01/2014
As a Referral Intake Specialist, I reached out telephonically to members to provided information on care
management in order to enroll them in the service. It is my responsibility to document the members account
with important health information for the care managers. I also employ research methodology to located and
enroll currently unmanaged members. I was instrumental in creating a successful research process.
 Promoted after 7 months of demonstrating great customer service and exceeding productivity
 Facilitate virtual and classroom trainings, mentor new associates
 Became a SME for testing new systems and processes
 Participated in a Member Win-Back Workshop Webinar and a Learning and Development video
o Systems used: CGX, CCP2, GCP, CI, MACESS, LEXIS NEXIS, NPI REGISTRY, HCAT
Coordinated Benefits Plans, Clearwater, FL
Claims Customer Service Representative 04/2013-12/2013
As a Claims customer service representative, it was my job to ensure that member and providers were
provided with accurate information on claims processes, billing procedures, and benefits for medical and
dental high deductible policies. My daily goal was to receive 80+ calls a day. I was provided training on plan
certificates and reading claims.
 Researched Grievances and Appeals and provided resolution
 Analyzed and investigated records, certificates, call documentation to determine claim payment issues
o Systems used: TRIZETTO, NEW WAVE, SDS
Universal Health Care Group, St. Petersburg, FL
Sr. Enrollment Service Representative 08/2012-04/2013
Enrollment Service Representative 01/2012-08/2012
In this role, I received inbound call from members with escalated enrollment or disenrollment concerns. The
purpose of this position was to prevent company CTM’s and to serve as a liaison for the member. I received
specialist training in Medicare guidelines for Enrollment and Disenrollment procedures.
 Promoted after 7 months for demonstrating leadership and training capabilities as well as the knowledge
of Medicare guidelines
 Worked with a team on the teams processes, training, and call scripting
 Provided coverage for the supervision of the team
 Completed coaching’s, side by sides, Quality Analysis
 Completed CTM research and analysis
 Verified qualifying medical conditions for SNP policies and Medicaid eligibility for dual eligible members
 Process address changes in accordance to Medicare guidance
o Systems used: MARX, FORTUNA, MEDICAID ELIGIBILITY PORTAL

3. Universal Health Care Group, St. Petersburg, FL
Member Service Representative I 8/2011-01/2012
The scope my duties as a Member Service Representative were to handle beneficiaries concerns with first call
resolution. I was trained on polices for Medicare and Medicaid benefits, claims, grievance and appeals,
provider networks, and coverage as well as CTM prevention. I was responsible for meeting productivity of 60
calls per day. I also received high quality scores because I provided members with accurate information.
 Promoted after 6 months of provided excellent customer service and demonstrating analytical skills
o Systems used: FORTUNA, EMDEON
2020 company, Tampa, FL
Sales Representative 01/2009 – 10/2010
In this role, I was a door to door sales representative for a cable products and services. I remained consistent
in meeting the daily production of 3 sales and working a minimum of 6 hours.
 Motivating other associates, leading team meetings, constructing teams and individual goals
 Assisted with daily reporting of team sales, scheduling and training
Accomplishments
Company: Humana at home
1. Treasure Chest Award 08/12/2014: Awarded for helping to create a better research process for the
team, exceeding productivity, and helping out fellow associate.
2. Shining Star Award 06/30/2015- Awarded for creating a better process for the team, mentoring and
helping to train the department.
3. Treasure Chest Award 07/29/2015- Awarded for facilitating a training class for other teams’
associates at the last minute on my teams process.