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Customer Service Representative 1 for Medi-Cal and Cal MediConnect Resume Example

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CUSTOMER SERVICE REPRESENTATIVE 1 FOR MEDI-CAL AND CAL MEDICONNECT
Summary

Seeking a position that will enable me to use my decision making, problem solving and excellent customer care skills. Call Center representative versed in customer support in multiple high call volume call centers. Skilled customer service representative committed to addressing customer concerns with speed, accuracy and professionalism. Superior computer skills and professional telephone etiquette.

Highlights

High customer service standards

Conflict resolution proficiency

Strong problem solving ability

Troubleshooting skills

Proficient with Microsoft Office Suite


    Accomplishments

    Managed call flow with up to 50 calls in queue per minute.

    Experience
    Customer Service Representative 1 for Medi-Cal and Cal MediConnect03/2014 to 09/2014Health NetRancho Cordova, CA
    • Resolves incoming calls concerning members eligibility, benefits, provider information, clinical, and pharmacy needs.
    • Composes routine and non-routine correspondence to answer benefits/provider inquiries in writing.
    • Coordinates membership changes such as members primary care physician.
    • Comprehensive resolution of pharmacy calls concerning benefit coverage, formulary coverage, vacation overrides, and utilization management requirements.
    • Performs inventory reduction, routine to mid-level, (i.e.
    • member inquiries, provide claim status details and may initiate claim adjustments, responds to emails, etc.) May participate in quality and efficiency workgroups to continuously improve quality member/customer satisfaction.
    • Analyze available programs, determine program eligibility and connect member to appropriate Health Advocates, Social Workers, Pharmacy Techs, and Pharmacists Verify the member is included in or targeted for any outreach or care gap programs and connect members to programs or services when appropriate.
    • Triage cases for assignment to the Case Management, Behavior Health, Health Management Programs and/or Member Outreach programs and document the status in appropriate systems.
    • Elevated level of empowerment to resolve disputes prior to escalating to Appeals and Grievances.
    • Proactively engages member with their wellness plan options.
    • Enhanced knowledge of medical terminology Triage cases to RN when the case exceeds extension of authority and the criteria is met.
    • Collaborates with the provider to ensure Continuity of Care is maintained on behalf of the member.
    • Ability to perform the following pharmacy related duties: Provide prescription related benefit coverage (e.g.
    • explanation of coverage or benefit summary related) Provide prescription formulary coverage using web posted printed formulary.
    • Provide status of a prior authorization requests.
    • Assist members may when and how to appeal a coverage decision.
    • Able to provide a brief description of coverage denial reason and alternatives as listed in the printed formulary.
    • Perform prescription claim overrides for vacation.
    • HIPAA and PCI compliance.
    Inbound Call Center Representative03/2013 to 01/2014Answernet/SigniusFair Oaks, CA
    • Answer inbound calls from various clients and customers.
    • Maintain customer telephone contacts with clients.
    • Train new hires on computer systems and office procedures.
    • Professionally handled customer complaints and determined effective solutions.
    • Communicated effectively with management, staff and the public.
    • Manage information on over 1000 business accounts.
    • Utilized TASCOM SQL Phone system to answer calls .Strike a positive tone with customers.
    • Handle a high influx of inbound calls within a dynamic call center.
    • Toggling between screens and inputting data while assisting customers on phone.
    • HIPAA and PCI compliance.
    • Made reasonable procedure exceptions to accommodate unusual customer requests.
    • Demonstrated mastery of customer service call script within specified timeframes.
    Receptionist11/2012 to 03/2013Matorr Office SolutionsCarmichael, CA
    • Answer all incoming calls and handled callers inquiries.
    • Provide clerical and word processing support.
    • Maintain filing system and file all documents.
    • Ensure efficiency by providing excellent office support.
    Inbound Call Center Representative03/2012 to 09/2012NetflixGreenwood Village, CO
    • Provide troubleshooting for Netflix customers.
    • Explaining billing and account issues when customers have concerns.
    • Troubleshoot connections issues to Netflix .Toggling between screens and inputting data while assisting customers on phone.
    • Deliver world class customer service and build customer loyalty.
    • Strive for one-call resolutions for customers.
    • Professionally handled customer complaints and determined effective solutions.
    • Provide information on new products and services.
    • Strike a positive tone with customers.
    • Handle a high influx of inbound calls within a dynamic call center.
    Tier 1 iPhone TSR08/2011 to 11/2011Iphone Apple Inc.Boulder, CO
    • Provided tech support and troubleshooting for Apple.
    • Toggling between screens and inputting data while assisting customers on phone.
    • Troubleshoot technical issues customers are having with their iPhone.
    • Work with the latest cell phone technologies.
    • Work with iPhones and MAC computers .Assisted in troubleshooting problems relating to operating system issues (MAC OS, WINDOWS OS).
    Inbound Call Center Representative /Shift Supervisor03/1996 to 02/2011AAA CommunicationsDenver, CO
    • Maintain customer telephone contacts with clients.
    • Train new hires on computer systems and office procedures.
    • Backfill for supervisor during meetings and vacations.
    • Professionally handled customer complaints and determined effective solutions.
    • Communicated effectively with management, staff and the public .Manage information on over 1000 business accounts.
    • HIPAA and PCI compliant.
    Education
    High School Diploma: General Studies1983Sacramento Union AcademyCarmichael, CA, USA
    Skills

    Call center, conflict resolution, MAC OS, medical terminology, Microsoft Office Suite, WINDOWS OS, problem solving skills, SQL, supervisor, tech support, multi-tasking, careful and active listener and professional and friendly.

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    Resume Overview

    Companies Worked For:

    • Health Net
    • Answernet/Signius
    • Matorr Office Solutions
    • Netflix
    • Iphone Apple Inc.
    • AAA Communications

    School Attended

    • Sacramento Union Academy

    Job Titles Held:

    • Customer Service Representative 1 for Medi-Cal and Cal MediConnect
    • Inbound Call Center Representative
    • Receptionist
    • Tier 1 iPhone TSR
    • Inbound Call Center Representative /Shift Supervisor

    Degrees

    • High School Diploma : General Studies 1983

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