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Customer Service Management

Hialeah, Florida, 33014, United States
May 25, 2010

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**** * **** ******, *******, Florida 33014-3731 ? Cell: 305.***.****



Energetic and resourceful leader, experienced in regulatory and

accreditation compliance specific to commercial managed care and Medicare

Advantage products with 13 years in the healthcare industry 7 of which in a

managerial role. Proficient in resource management and project management.

Excellent verbal and written communication skills. Possess strong

leadership, organizational, and planning skills with an eye for problem

solving. Proven ability to communicate effectively at all levels with an

emphasis on collaboration and relationship building. Bilingual, fluent in

English and Spanish (oral and written).



Manager / Grievance and Appeals (June 2002 - July 2009)

- Provide leadership and direction through effective performance

management to a team of exempt and non-exempt full-time employees

- Ensure appropriate handling of formal written member grievance and

appeals, informal oral member grievances received in a call center

environment, and formal written provider disputes

- Hire, develop, coach, support and mentor staff in order to maximize

employee performance

- Handle escalated issues telephonically or in person providing

education and guidance to members and providers to maximize benefits

- Manage daily operations by effectively developing and monitoring

departmental goals, ensuring that both service and quality standards

are achieved

- Direct oversight of departmental compliance with government and

accreditation agencies (i.e. CMS, OIR, AHCA, and NCQA); responsible

for researching, interpreting, and applying laws and regulation

guidelines to formulate and/or update company/department standard

operating procedures, program policies, and manuals

- Ensure effective quality control procedures are in place and followed

by conducting thorough audits and ongoing monitoring

- Oversight of department tracking database; responsible for ensuring

pertinent data is compiled and monitored for regulatory and

accreditation reporting standards

- Formulate and manage annual budget of $1M

- Oversee project development and delivery

- Lead Representative for BCBSF in all external on-site audits which

include CMS and NCQA

- Review and approve all grievance and appeals related correspondence

submitted to CMS for approval

- Member of various internal regulatory compliance assurance committees

- Facilitate and lead cross-functional teams to identify areas of

opportunity and resolve issues related to grievance and appeals,

sales, enrollment, utilization management, payment of claims, benefits

administration, and member services

- Chairman of the BCBSF Grievance Committee, responsible for reviewing

all formal non-clinical grievances and appeals and voting member of

the BCBSF Internal Review Panel, responsible for reviewing all

clinical grievances and appeals

- Responsible for attending and responding to administrative law judge

(ALJ) hearings for Medicare grievance/appeal disputes

Key Achievements

- Achieved a passing rating from CMS for the on-site audit conducted in

Sept 2008

- Achieved a commendable rating from NCQA for the on-site audit

conducted in March 2009

- Integrated individual business area workforce into a department wide

view to leverage resource needs and move away from product division

thereby streamlining business practices and achieving a cost savings

of $125K

- Created clearly defined roles and responsibilities for each position

within the department to ensure effective use of available resources,

facilitating organizational effectiveness and decision making

- Lead initiative while collaborating with IT Developers to create a

common platform in which to capture all grievance and appeals. This

project integrated business processes previously divided by product

and geographical location to ensure standardization, consistency, and

the use of single source data.

- Developed service level agreements with other departments within the

organization to ensure compliance across the enterprise

Compliance Analyst / Grievance and Appeals (March 2000 - June 2002)

- Interpreted regulatory and accreditation guidelines to develop and

maintain departmental standard operating procedures (SOP)

- Created grievance and appeals related correspondence within compliance


- Facilitated and lead process improvement projects and initiatives

related to grievance and appeals CMS compliance

- Supported Six Sigma initiatives

- Supported various internal regulatory compliance assurance committees

- Voting member of the BCBSF Grievance Committee, responsible for

reviewing all formal non-clinical grievances and appeals

- Conducted monthly internal audits to monitor performance and ensure

state and federal government and regulatory compliance

standards/department protocols are adhered to

- Developed continuous training material and facilitated group training

sessions as needed

Key Achievements

- Identified and implemented process improvements to bring department in

compliance with regulatory and accreditation standards

- Developed case file tracking process to maintain grievance and appeal

files secure and accounted for

Operations Analyst III / Business Management (October 1998 - March 2000)

- Collaborated with South Florida business units to evaluate performance

of medical and administrative cost savings projects and lead related

process improvement initiatives as needed.

- Compiled geographical operational data and reported progress goals to

the Southern Geographical Business Unit (SGBU) Vice President

- Provided ad-hoc reporting, analysis, and project management as needed

- Monitor external vendor service agreements through monthly accounts

payable reconciliations

- Lead annual budget process and provided training to cost center

managers on budget guidance

- Reviewed and analyzed cost center budget variances, identified areas

of concern and provided recommendations

- Processed multiple account maintenance activities (i.e. journal

entries, expense report audits, check request audits, and chargeback


- Serve as subject matter expert on projects and workgroups

- Supported NCQA preparations and on-site audit

Key Achievements

- Identified billing discrepancies with quality oncology vendor program,

which upon reconciliation resulted in a $250K savings

Healthcare Industry Analyst / Utilization and Care Management (February

1998 - October 1998)

- Extracted, prepared, and analyzed multiple key indicator goals against

benchmarks (i.e. facility and physician utilization and readmissions)

- Identified, developed, recommended, and implemented process and

program improvements

- Collaborated with all levels of Sr. Leadership Team in business

process recommendations and program implementations

Sr. Quality Analyst / Group Membership & Billing (July 1997 - February


- Conducted monthly internal audits to monitor performance and ensure

department protocols are being adhered to

- Developed continuous training material and facilitated group training

sessions as needed

- Identified, documented, and provided guidance to individual team

members regarding process and operational workflow as needed

- Compiled audit findings and provided monthly reports to management


- Lead the development and implementation of the In-Line Quality Audit


- Served as Co-chairman of the Continued Quality Improvement Workgroup,

which identified gaps in operational functions and maintained and

updated standard operating procedures as needed

Personal Service Representative / Group Membership & Billing (June 1996 -

July 1997)

- Monitored and provided service to approximately 250 group accounts

- Performed monthly group account financial reconciliations and

monitored delinquency status

Universal Aviation Services, Miami, FL July 1994 - May 1996

Supervisor - Passenger Services

- Provided leadership and direction to a team of 10 Passenger Service

Agents through effective performance management

- Oversight of daily operations of the international ticket counter

operations, prepared flight documents including U.S. Customs

clearance, weight and balance of aircraft, and various operational


- Provided training to newly hired employees on company policies, flight

procedures, and U.S. Customs and Immigration regulations

Carnival Cruise Lines, Miami, FL November 1992 - July


Customer Service Representative / Reservations

- Received and serviced inbound calls from travel agents and individual

customers in a call center environment

- Served on the Continuous Quality Committee which facilitated enhanced

training modules in a classroom environment


Six-Sigma Yellow Belt


Proficient in Microsoft Office Suite Products (Word, Excel, Power Point,

Outlook, Project, and Access)

Familiar with TSO, SAS, and Quest data reporting tools


Behavioral Interviewing * Foundations of Leadership * Fundamentals of

Managing People

Fundamentals of Managing Work * Coaching for Improved Performance

Time Management * 7 Habits of Highly Effective People * Difficult


Leading the Performance Management Process


High School Diploma

Some College

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