James Liwanag

Communication graduate with a strong foundation in research, news writing, editorial writing, feature writing, communication, and broadcasting. I am skilled in gathering and verifying information, identifying compelling story angles, and transforming complex ideas into clear, accurate, and engaging content. My journalism training has strengthened my ability to conduct thorough research, develop well-structured stories, and journalistic ethics.

I bring strong writing, critical-thinking, interviewing, and editorial skills. I am eager to contribute these skills to a newsroom or media organization where I can create meaningful content, support responsible journalism, and continue developing as a versatile and effective journalist.

Member Services Representative - Dual Special Needs Healthcare Plan (Medicare and Medicaid) and Medicare Advantage Plan - Concentrix

(2024-06 - 2025-12)

• serve as the primary contact for members and providers regarding DSNP and Medicare Advantage plans, addressing inquiries across medical and supplemental benefits
• verify and explain eligibility, coverage, and benefits, including medical services, prescription drugs, and special plan inclusions
• assist with claims, billing inquiries, and issue resolution for medical and pharmacy-related concerns
• support prescription drug coverage (Part D) by explaining formularies, prior authorizations, and medication cost-sharing
• guide members on accessing over-the-counter (OTC) benefits, including ordering processes and eligible items
• provide information and coordination for dental, vision, and hearing benefits, including provider networks and coverage limits
• coordinate care services and referrals, especially for DSNP members with chronic conditions or special healthcare needs

Pharmacy/Prescription Drug Plan Member Services Representative - Convey Health Solutions

(2023-09 - 2024-03)

• assisting healthcare members about their billing, medications' shared costs, claims, authorizations/appeals' statuses and coverage determinations of their Prescription Drug Plan
• informing them about their benefit coverage, medications that are covered and alternatives for non-covered medications
• providing the process on updating their Coordination of Benefits to avoid any late enrollment penalty and claim's denial
• assisted members with prescription claim status, including paid, rejected, and reversed claims
• investigated pharmacy claim rejections related to prior authorization, formulary issues, quantity limits, and eligibility
• initiated reprocessing of prescription claims when errors were identified or updates were applied

Medical Provider Services Representative - Carelon Global Solutions

(2021-10 - 2023-03)

• serve as the main point of contact for healthcare providers, handling inquiries on claims, eligibility, and authorizations
• assist with claims processing and follow-ups, including resolving denied or delayed claims
• verify patient eligibility and benefits, and explain coverage details to providers
• support prior authorization and referral requests in line with insurance guidelines
• document interactions, resolve issues efficiently, and escalate complex concerns when needed
• coordinate with internal teams (claims, billing, utilization review) to resolve provider concerns
• ensure compliance with healthcare policies, regulations, and data privacy standards
• maintain service quality and meet performance metrics (e.g., turnaround time, accuracy, customer satisfaction)
• stay updated on policy changes, system updates, and process improvements

Bachelor of Arts - Communication - University of Caloocan City