Customer Service Representative

OBJECTIVE___________________________________________________________________

________

To obtain a challenging position where my managerial and analytical skills

can be fully utilized to support a progressive health care organization.

PROFESSIONAL EXPEERIENCE__ _______

_______________________________________

Niko Developers-Operations Manager/Owner

May 2004- Present

. Benefit Administrator for over 10 employees, helped create and

establish a solid, positive and productive work environment.

. Provided telephone assistance and problem resolution to clients as

needed.

. Research and order all supply materials and negotiate contract cost

effectiveness for small residential, large hotel, and many other types

of projects.

. Ensured project completions met timelines and budget requirements.

. Quality control Management during and after installation

. Manage project and update employees concerning problems and

troubleshooting structural issues during installation.

. Establishing valuable vendor contracts for suppliers of raw materials.

Wellpoint Pharmacy Management

September 2003-May 2004

Client Partner

. Managed clientele daily expectations with a total membership exceeding

3M

. Organized and facilitated database conversion

. Maintained and updated knowledge of PBM claims processing system

testing to ensure accurate implementation of prescription benefits.

. Maintained integrity of benefits by auditing and documenting benefit

structures.

. Performed final review and approval of production changes.

Aetna US Healthcare/Prudential

March 1998 - September 2003

Complaint & Appeal Resolution Analyst

. Managed complaint/appeal scenarios for all products and coordinated

responses from multiple business units.

. Ensured timely customer focused response to complaints and appeals.

. Recommended "best practice' business solutions.

. Performed final review and approval of production changes

. Processed claims for Midwest and California providers

. Reviewed HMO and PPO member plans

. Extensive training and processing

. Managed work flow and accountability

. Workflow for Work at Home Associates

. Pull reports and distribute amongst team

. Correspondence via Lotus Notes and Airborne

. Quality review of hospital claims completed weekly

Care America Health plan

March 1997- March 1998

Senior Claims Examiner

. Examining and processing HMO claims

. Adhered to contracted stipulations

. Coded Financial responsibilities of claims

. Reported status to providers/members

Wellpoint Pharmacy Management

March 1997- March 1998

Customer Service Representative

. Resolved customer inquires

. Explained products and services

. Liaison between customer and company marketing, sales, distribution

and accounting

. Process customer orders

. Ensured accurate pricing and delivery

Personal Insurance Administrators

December 1992-February 1995

Customer Service Representative/Claims Examiner

. Handled members and provider calls

. Processed HMO and PPO medical and hospital claims

. Verified insurance for all plans

. Adhered to contracted stipulations

Biles and Cook Administrators

March 1991 - December 1992

Claims Supervisor

. Supervised claims department

. Processed annual reviews

. Monitored daily workflow

. Trained new employees

. Assisted management with new hires

. Implemented policies and procedures

EDUCATION___________________________________________________________________

_______

Oxnard College General Studies

Fall 1986

Channel Islands High School General Studies

Spring 1986

REFERENCES

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Furnished Upon Request

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