Demonstrate sense of urgency in a busy call center environments in both retail and telecommunication industries. Possess exceptional ability to build productive relationships, resolve complex issues, and win customer loyalty. Excellent interpersonal skills, ability to work well with others, in both supervisory or support staff roles.
Independent judgment and decision
Knowledge of Medicaid statutes and making regulations
Promotes positive behavior
Program Coordinator I, 06/2014
to Current Sunshine Health – Sunrise,
Initiate authorization requests for output or input services in keeping with the prior authorization list. Research claims inquiry specific to the department and responsibility.
Perform tasks necessary to promote member compliance such as verifying appointments, obtaining lab results. Assess and monitor inpatient census.
Screen for eligibility and benefits. Identify members without a PCP and refer to Member Services. Screen members by priority for case management (CM) assessment. Perform transition of care duties to include but not limited to, contact the member's attending physician, member or medical power of attorney, other medical providers (home health agencies, equipment vendors) for information pertaining to special needs.
Data enter assessments and authorizations into the system.
Assist with special projects as needed.
Medicare/Medicaid Claims Representative, 10/2011
to 06/2014 Molina Healthcare of Florida – Doral,
Meeting all department standards by 95% or higher.
Explain plan's procedures, protocols, benefits, services and information to members and providers as required.
Ensure that all assigned provider issues are resolved and communicated to the provider within appropriate timeframes and report resolutions that are unfavorable to the appropriate Provider Relations Representative.
Assist providers with escalated inquiries including but not limited to; verifying proper medical coding, claim status, explanation of benefits, negative balance requests, claim payments and denials, appeal procedures and appeal status.
Document all inquires and complaints completely and thoroughly, Adhere to all HIPAA, State and Federal requirements, and regulations at all times in existing and future lines of business.
Provider Service Advocate V- Lead Representative, 02/2007
to 12/2009 Blue Cross and Blue Shield of Florida – Miami,
Resolved issues on escalated calls from providers in regards to claim issues.
Supported team members in claim inquiries both telephone and written.
Exceeded claims processing daily quotas 100% of the time.
Answered nearly 60 inbound calls daily to assist providers with claims, benefits, and contracting inquires.
Always meeting expectations in quality, adherence and production scores while gaining a deep understanding and foundation on health insurance functions on many levels.
Assisted providers with written and phone inquires regarding claims, benefits, contracts, and fees schedules.
Provided resolutions to providers via letter and documenting all issues.
Built working relationships with healthcare providers in order to insure excellent customer.
Service Advocate I, 02/2009
to 03/2011 At&t – Miami,
Exceeded monthly sales quotas 100% of the time. Trained and supported team members to assist with closing sales. Able to successfully up sale customer's on additional AT&T products.
Answered nearly 100 inbound calls daily to assist customers with various products, services and billing inquires.
Consulted with customers to recommend and sell a variety of AT&T products and services to meet the customers' needs.
Provided AT&T customers with a positive sales and service experience. Interacted with multiple online systems while speaking with customers.
Assisted customer with billing inquires as well as assisted customers in making payments to their AT&T account.
Miami Bus Operator, 01/2005
to 01/2007 Miami Dade County Transit – Miami,
Completed training required in all areas of bus driving and safety.
Provided excelled customer service to over 500 rider's per day.
Assisted passengers with information on city geography and routes.
Completed ethics related training.
Contracting Specialist -Lead Representative, Precision Response Corporation PRC Direct TV – Miami,
Processed contracts for commercial accounts.
Distributed promotional materials to prospective and current customers through facsimile and e-mails.
Maintained customer accounts by applying payments, initiating connections and disconnections, and researching accounts through utilization of queries.
High School Diploma: Vocational Studies,
1996 Miami Norland Senior High - Miami,
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Companies Worked For:
Molina Healthcare of Florida
Blue Cross and Blue Shield of Florida
Miami Dade County Transit
Precision Response Corporation PRC Direct TV
Miami Norland Senior High
Job Titles Held:
Program Coordinator I
Medicare/Medicaid Claims Representative
Provider Service Advocate V- Lead Representative
Service Advocate I
Miami Bus Operator
Contracting Specialist -Lead Representative
High School Diploma : Vocational Studies , 1996
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