customer resoluation specialist iii resume example with 11+ years of experience

(555) 432-1000,
Montgomery Street, San Francisco, CA 94105
Energetic and enthusiastic insurance professional with over 10 years that is motivated to succeed in a fast-paced and deadline-driven professional environment. Comprehensive knowledge of health insurance, with special knowledge of individual, small group and short-term health insurance. Meticulous claims investigator effective at offering superior oral and written communication skills. 
  • MS Word Windows 98-2003,
  • XP Internet/Web Sites
  • MS Power Point
  • MS Access MS Outlook/Lotus Notes
  • MS Excel Windows 2007-2013
  • Claims file management processes
  • Litigation resolution
  • Strong interpersonal and communication skills
  • Self-directed
  • Report writing
  • Analytical
  • Team player
  • Critical thinker
Concordia University - Professional Counseling Mequon, WI Expected in Master of Science : - GPA : November 2013 - present Concordia University-Wisconsin Mequon, WI
University of Phoenix Milwaukee, WI Expected in 2012 Bachelor of Science : Psychology - GPA : December 2010-October 2012, University of Phoenix, Milwaukee, WI Bachelor of Science Psychology
University of Phoenix Milwaukee, WI Expected in 2010 Associate of Arts : Psychology - GPA : January 2009-November 2010, University of Phoenix, Milwaukee, WI Associate of Arts Degree (Concentration in Psychology)
Received recognition award for idea for a difficult account.
Promoted to Customer Resolution Specialist II  in 1 year with the Company
Devoted Health - Customer Resoluation Specialist III
Philadelphia, PA, 05/2015 - Current
Milwaukee, WI Correspondence ◦ Providing written and/or verbal responses to inquires and administrative actions to customer's appeals in accordance with regulatory requirements and service standards. ◦ Accurately documenting and logging information into the department database to ensure accurate reporting of market conduct exams. ◦ Researching the insured's contract provisions, state mandates, and administrative guidelines to determine if additional benefits are available. ◦ Investigate and research all aspects of the customer's issue at hand by using the mainframe system, departmental guidelines and compliance information in conjunction with the customer's contract and any specific state mandates. ◦ Resolve correspondence consistent with departmental guidelines by telephoning or written, clear, concise, customer oriented ad-hoc letters, keeping with internal and state regulatory requirements. ◦ Collaborate with other department key contacts to research and request information leading information to issue resolution. Follow-up to ensure the issue is resolved in accordance with departmental guidelines. ◦ Preparing second level grievances for review. Identify reliance issues, ensuring all issues are documented and forwarded to Supervisor for possible exception. ◦ Participate on department and other departments projects ◦ Mentoring new employees on system database and department guidelines/workflow
Bd (Becton, Dickinson And Company) - Claims Specialist
New York, NY, 02/2006 - 04/2008
Reduced loss ratios through fair and prompt processing of claims. ◦ Process incoming insured medical claims according to the terms of their policy contract language, state mandates, state compliance, and policy riders ◦ Follow up on claims pending for additional information, such as medical records, hospital reports, physical therapy reports or an itemized bill ◦ Refer claims requiring additional investigation to other units/areas ◦ Obtain additional information needed to determine eligibility of claims ◦ Contact providers and insured and missing information not submitted with the claim ◦ Review and adjudicates all types of medical claims through the claim system ◦ Mentor new analyst by having side by side ◦ Communicate with internal and external insured and providers ◦ Contacting networks for correct re-pricing/discount amount not listed on claims forms
Assurant Health - Customer Care Specialist II
City, STATE, 06/2002 - 03/2006
◦ Personalize all interactions (oral and/or written) with customers so they feel confident, secure, respected, and cared about. Use a positive greeting along with a confident, conversational, and jargon-free communication delivery approach. ◦ Effectively listen during inbound and/or outbound calls or in-person interactions to identify and anticipate an individual's needs wants and emotions. While maintaining a level of professionalism as an Assurant Health representative. ◦ Reinforce the purchase decision and value proposition for doing business with Assurant Health. Appropriately convey a genuine appreciation and thanks. ◦ Provide complete, accurate, premium services, claim processing, correspondence, and other necessary areas trained; and act on behalf of customers (a liaison) with the appropriate internal and/or external resource to address the customer's need. ◦ Take ownership by providing follow-up and contact the appropriate internal and/or external resources to address the need promptly if first call resolution ◦ Keep commitments and proactively follow-up with customers about information that is important to them and/or will help improve their health, use of health care and cost related needs. ◦ Identify trends and other opportunities to improve the experience of Assurant Health through all interactions with customer's agents, providers, third party vendors, Assurant Health employees, etc. ◦ Continuously provide and be open to feedback, ideas and other best practices that support positive balancing the needs of customers and/or stakeholders with Assurant Health. Participate on project teams as needed. ◦ Continuously learn and perform other administrative responsibilities including but not limited to correspondence, premium services and claims' processing, systems, tracking, reports, documentations, etc.
Correspondence, Benefits, Database, Documenting, Logging, Mainframe, Mentoring, Workflow, Claims, Best Practices, Confident, Greeting, Liaison, Outbound Calls, Value Proposition, Business Management, Medical Claims, Medical Records, Mentor, Pricing, Therapy, Associate, Access, Excel, Lotus Notes, Microsoft Windows, Ms Access, Ms Excel, Ms Outlook, Ms Word, Outlook, Windows 98, Word

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Resume Overview

School Attended

  • Concordia University - Professional Counseling
  • University of Phoenix
  • University of Phoenix

Job Titles Held:

  • Customer Resoluation Specialist III
  • Claims Specialist
  • Customer Care Specialist II


  • Master of Science
  • Bachelor of Science
  • Associate of Arts

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