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Customer Service Health Insurance

Miami, Florida, 33142, United States
March 18, 2011

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**** ** **** ****** . *****, FL 33142

Phone: 305-***-**** . e-mail:

Health Insurance professional

with 13+ years of progressive experience

Objective: To obtain a position which will enable me to utilize my

training, skills and experience with opportunity for challenge

and growth

Languages: English . Some Spanish


. Delegates and completes tasks with equal efficacy, and demonstrates

cross-functional expertise

. Proven leader, thrives under pressure and utilizes excellent analytical


. Ideal blend of academic background and "real-world" execution

. Excellent interpersonal, written and verbal skills and performs well

under pressure

. Repeatedly lauded as a superior team-player, astute to detail and

consistently exceeds expectations


Barry University, Miami Shores, FL

Bachelor of Science Degree in Professional Administration


Tuskegee University, Tuskegee, AL

Electrical Engineering Program

1986 - 1989

Employment Experience:

Jackson Memorial Health Plan, Miami, FL Quality Specialist

3/08 - 5/10

Selected to represent the Grievance and Appeals Department during the

implementation and launch of the Plan's Medicare Choice Program; developed

the company-wide mandatory Grievance and Appeals training and test; adhered

to regulations and submitted reports to oversight entities, such as The

Agency for Health Care Administration (AHCA), The Subscriber Assistance

Program (SAP), and The Centers for Medicare and Medicaid Services; resolved

expedited grievances and appeals with 100% accuracy and timeliness; created

training tools and conducted oral presentations; served as the Plan's

contact person for the Consumer Assessment of Healthcare Providers and

Systems (CAHPS) Survey; composed policies and procedures, and constructed a

tracking system to house applicable data; supported development and

implementation of quality improvement functions, ensuring compliance with

strict state and federal regulations; generated and maintained records and

reports resulting in full compliance with federal and state oversight

entities; researched, resolved, and responded to complaints and inquiries

from regulatory agencies; identified trends, barriers, and opportunities

which were used to improve overall customer satisfaction

Miami-Dade County Fire Rescue, Miami, FL Office Specialist/HR

Specialist 5/07 - 3/08

Performed Human Resource support and administrative duties; maintained

accurate, up-to-date employee files; processed public record requests;

actively participated in conferences and other educational opportunities

Blue Cross Blue Shield of Florida, Miami, FL Senior Grievance Appeals

Coordinator 8/00 - 1/06

Customer Service Representative 6/95 - 8/00

Managed customer relations and provided exemplary service to all customers

and providers, which resulted perfect audit scores; analyzed, investigated

and resolved billing problems, and other insurance status inquiries; acted

as team leader, and successfully won over irate customers; selected to

train new call center employees; adhered to The Health Insurance

Portability and Accountability Act of 1996 (HIPAA), and other Privacy

Rules; resolved health service complaints, grievances and appeals in a

timely manner with 100% accuracy.

Computer Skills: Internet . E-mail . Outlook . Excel . MSWord .


References available upon request

Contact this candidate