Jessica Claire
  • Montgomery Street, San Francisco, CA 94105
  • Home: (555) 432-1000
  • Cell:

An accomplished results-driven professional with 15+ years of experience , with expertise in creating and implementing programs to improve business operations.Adept at recruiting, selection and retention strategies. Able to provide recommendations for improvement; highly skilled in preparing for restructuring, downsizing, change management, morale and retention. Strong relationship-building and effective collaboration with management, colleagues and clients. Ability to create and execute training, coaching and counseling programs.

  • Management & Leadership
  • Coaching & Counseling
  • Training & Development
  • Talent Acquisition & Retention Planning
  • Project Management
  • Labor Law & Regulatory Compliance
  • Research Analysis
  • Grievance & Conflict Proceedings
  • Mediation & Problem Solving
  • Business Process Improvements
  • Network Relations
  • Recruiting

Developed and Delivered the training for the Screening, Briefing, Intervention, Referral and Treatment (SBIRT) program for the providers and office managers annual meeting for the Inland Empire.

Provider Services Representative II, 11/2013 to Current
W.R. Berkley CorporationLawrenceville, GA,

Responsible for supporting various provider services functions with an emphasis on education, training and advocacy of healthcare partners.

Subject Matter Expert (SME) on Local, State and Governmental Policies and Procedures

Leadership, Coaching and Training of fellow colleagues; Research Analysis and Conflict

Project Management and Business Process Improvements

Claims Representative II, 08/2009 to 09/2012
WellPoint IncCity, STATE,

Accountable for Commercial and Medicare claims as well as, error reports

Performed Research Analysis and Conflict Resolution

Established new partnering relationships for new business

Recruitment, Coaching and Training to colleagues on updates

Project Management and Promotion of Best Practices

Medicare Grievance and Appeals Analyst, 06/2007 to 08/2009
AetnaCity, STATE,

Leadership, Subject Matter Expert (SME) on Medicare grievance and appeals, benefits, claims, eligibility and enrollment

Responsible for Network Management, Labor Relations and Regulatory Compliance

Project Management, Member Retention and Advocacy

Bachelor of Science: Human Services, Expected in 2012
University of Phoenix - Ontario, CA

Currently enrolled into MBA

Bachelor of Science: Human Services, Expected in 10/2012
University of Phoenix - ,
Human Services
Sunrise Assisted Living Facility (2010) Lanterman Development Center (2011) Reach Out Mentoring (2011-2012): , Expected in
- ,
Molina Healthcare Inc Pomona, CA December 2013-Present Provider Service Representative II Responsible for supporting various provider services functions with an emphasis on working externally with Plan's Providers to educate, advocate and engage as valuable partners. Subject Matter Expert on provider services and project management matters. Responsible for resolving provider issues that cross departmental lines. Training other Provider Services Representatives as appropriate. Engage with high volume, high visibility providers to ensure provider satisfaction. Oversee projects, develop, organize and analyze documents for implementation of new processes and procedures as prescribed by Plan policies. WellPoint Pomona, CA Sept. 2009 - October 2012 Claims Representative II Accountable for processing commercial PPO, HMO, POS and Medicare Claims, as well as for working error reports, conducting research, and working with members and providers to pay claims in a timely manner. Establish and maintained interpersonal relationships. Evaluation of information and compliance determination. Analyzing information and evaluating results to choose the best solution and solve problems. Jessica. Claire PAGE 2 Aetna Rancho Cucamonga, CA Jul. 2007 - Sept. 2009 Medicare Grievance & Appeal Analyst Tasked with handling Medicare grievance/appeals and claims/enrollment issues, analyzing medical cases for appropriateness, and conforming with compliance/regulatory guidelines Worked with in/out-of-network providers and IPAs. Project Management via use of relevant information to determine compliance with project guidelines and standards. Kaiser Permanente Bellflower, CA/Atlanta, GA Sept. 1999 - Oct. 2005 Apr. 2006 - Jan. 2007 Health Plan Representative/Claims Customer Service Associate II Provided high quality service to internal/external customers, supervised CSRs, and handled eligibility, benefits, claim updates and inquiries. Documented and resolved HMO patient complaints and CMS (Medicare) complaints by identifying problems and coordinating appropriate action plans for resolution. Interpreted contract and benefit specifics and handled enrollment processing for individual, Medicare, and Medicaid programs. Implemented regulatory guidelines to ensure member satisfaction and positive relations in a labor management environment. Provided service to internal/external customers regarding eligibility, benefits, out of area coverage, claim updates and inquiries and reimbursements. Managed large case loads of complex issues with high level negotiations, conducted interviews with Medical Chiefs and Quality Assurance, and handled case management investigation, preparation and presentation. Interpreted contract and benefit specifics to internal and external clients and handled enrollment processing for individual, Medicare/Medicaid programs. Provided technical support to members using the Kaiser Permanente website, troubleshot issues, verified system operations, and provided step-by-step instructions to solve problems. Enforced regulatory guidelines to ensure member satisfaction and compliance with industry standards. Apria Healthcare Riverside, CA Oct. 2005 - Apr. 2006 Senior Customer Service Lead Handled complex orders from different referral sources, provided customer service, and coordinated the delivery and set-up of supplies and services with appropriate personnel. Coached/trained staff, organized work assignments, and ensured that work performance was accurate and efficient. Enforced company policies, procedures, and regulatory compliance with customer service representatives, as well as resolved patient complaints by identifying problems and coordinating appropriate action plans.
Assisted Living, business operations, Human Resources, Leadership, Regulatory Compliance, Mentoring, Excel, MS Office, PowerPoint, Word, Network, Project Management, quality improvement, File Maintenance, Research

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School Attended

  • University of Phoenix
  • University of Phoenix

Job Titles Held:

  • Provider Services Representative II
  • Claims Representative II
  • Medicare Grievance and Appeals Analyst


  • Bachelor of Science
  • Bachelor of Science
  • Sunrise Assisted Living Facility (2010) Lanterman Development Center (2011) Reach Out Mentoring (2011-2012)

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