Customer Service Health Insurance
Resume:
STANLEY JEROME ROBERTS
**** ****** **., ************, **. 32205
E-mail: ***************@*****.***
Career Objective
In developing a new career for myself, my objective is to join a firm that has a professional atmosphere, and encourages
their employees to be creative and discover new opportunities.
My preference is to obtain a position that will allow me to utilize all my skills: Office support, Human resources,
Research, Appeals and Grievances, Security expert (U.S. military (NAVY), and CSC. NFL. Systems Tester (IT) Case
Support Specialist, Health Insurance Advocate, or customer service. I am a fast learner, self starter, dedicated to my
work, and always ready to take on a new task. I would be a great asset to your company.
Work History
BroadPath Inc., Tucson, Arizona
October 2012 to April 2013 Job Title: Appeals Specialist/Proof Reader
(National Government Services PA)
MEDICARE/MEDICAID
• Duties: Proof read customer and provider appeals letters regarding provisions of service and benefit
coverage, and claim issues and resolutions.
• Ensures appropriate punctuation, grammar, format, and alignment of appeals letters before letters
are mailed to recipients.
• Sent with corrections and other resolutions to appeals representatives within specified timeframes for
corrections and to management for records and training.
AEROTEK Inc., Cincinnati, Ohio
October 2011 to April 2012 Job Title: Appeals & Grievance Specialist (Anthem
BCBS Ohio) MEDICARE/MEDICAID
• Duties: Investigates and reviews customer and provider grievances and appeals regarding provision
of service and benefit coverage issues.
• Triages clinical and non-clinical inquiries, grievances and appeals, prepares case files for member
grievance committees/hearings. Summarizes and presents essential information for the clinical specialist or
medical director and legal counsel. Responds to oral and written complaints.
• Ensures appropriate resolution to inquiries, grievances and appeals within specified timeframes
established by either regulatory/accreditation agencies or customer needs. Contacts customers and providers
to gather information and communicate disposition of case and document interactions .
BroadPath Inc., Tucson, Arizona
October 2009 to October 2011 Job Title: Service Professional (CIGNA
TN/CIGNA TX) MEDICARE/MEDICAID
• Duties: Assist clients with new and ongoing projects. Expert in the Health Insurance industry.
Answer questions regarding Medicare claims, status, eligibility, and coverage. Verifying if claim priced
correctly, speak with providers about claims and status. Worked special projects for client to have
outstanding issues researched and resolved. Advanced knowledge of products and services. Research and
resolve problems using resources provided by company. Delivered and resolved service inquiries, improved
benefit communications, claim and member services and billing resolutions.
• Provide customer service for various participants within various managed care programs including
members, providers, internal departments, covering topics such as claim status, eligibility, coverage, appeals
and general provider/member inquiries.
• Perform claim review to assure accurate processing and/or to establish reprocessing of claims and
performed audits to ensure the highest level of integrity with claim processing, correspondence, and customer
service requests.
The Jacobson Group, Chicago, Illinois
September 2008 to October 2009 Job Title: Service Professional (ANTHEM OH)
• Duties: Assist clients with new and ongoing projects. Expert in the Health Insurance industry.
Delivered and resolved service inquiries, improved benefit communications, claim and member services and
billing resolutions.
• Provide customer service for various participants within various managed care programs including
members, providers, internal departments, covering topics such as claim status, eligibility, coverage, appeals
and general provider/member inquiries.
• Perform claim review to assure accurate processing and/or re-process(claims adjustments) claims
and performed audits to ensure the highest level of integrity with claim processing, correspondence, and
customer service requests.
• Perform configuration to facets for Claims/Provider’s to be paid accordingly.
• Review provider/member formal/informal appeals and grievances within compliance of state laws.
PerotSystems, Plano, Texas
February 2008 to September 2008 Job Title: Service Professional (BCBS CO)
• Duties: Assist clients with new and ongoing projects. Expert in the Health Insurance industry.
Duties: Assist clients with new and ongoing projects. Expert in the Health Insurance industry. Delivered and
resolved service inquiries, improved benefit communications, claim and member services and billing
resolutions.
• Provide customer service for various participants within various managed care programs including
members, providers, internal departments, covering topics such as claim status, eligibility, coverage, appeals
and general provider/member inquiries.
• Perform claim review to assure accurate processing and/or to establish reprocessing of claims and
performed audits to ensure the highest level of integrity with claim processing, correspondence, and customer
service requests.
• Perform configuration to facets for Claims/Provider’s to be paid accordingly.
• Review provider/member formal/informal appeals and grievances within compliance of state laws.
The Jacobson Group, Chicago, Illinois
September 2007 to September 2008 Job Title: Service Professional (BCBS KS)
• Duties: Assist clients with new and ongoing projects. Expert in the Health Insurance industry.
Delivered and resolved service inquiries, improved benefit communications, claim and member services and
billing resolutions.
• Provide customer service for various participants within various managed care programs including
members, providers, internal departments, covering topics such as claim status, eligibility, coverage, appeals
and general provider/member inquiries.
• Perform claim review to assure accurate processing and/or to establish reprocessing of claims and
performed audits to ensure the highest level of integrity with claim processing, correspondence, and customer
service requests.
• Perform configuration to Facets for Claims/Provider’s to be paid accordingly.
• Review provider/member formal/informal appeals and grievances within compliance of state laws.
Blue Cross and Blue Shield, Jacksonville, Florida
January 2005 to January 2007 Job Title: Service Advocate II
Duties: Assist Medicare Beneficiaries with Medicare benefits. Explain eligibility, Medicare Prescription Drug Program,
Covered/non-covered procedures, Use of the Social Security Web-Site and Medicare Web-Site to assist beneficiaries in
ordering medicare cards/replacement cards, Prescription Drug Cards, Membership enrollment.
• Process and adjust claims according to plan procedures and policies.
• Perform claim review to assure accurate processing and/or reprocessing of claims and performed
audits to ensure the highest level of integrity with both claim processing, correspondence, and customer
service requests.
• Answer questions regarding claims, status, eligibility, and coverage, provider relations, benefits and
enrollment, Advanced knowledge of products and services.
• Research and resolve problems using resources provided by company. Follow-up with providers and
members regarding claim and eligibility and adjustments status via call backs or correspondence.
• Delivered and resolved service inquiries, Membership enrollment, improved benefit communications,
claim and member services and billing resolutions.
• Provide customer service for various participants within various managed care programs including
members, providers, internal departments, covering topics such as claim status, eligibility, coverage, appeals
and general provider/member inquiries.
Citistreet Inc, Jacksonville, Florida
January 1998 to February 2004 Job Title: Benefit Analyst
Duties: Perform pension calculations, research, troubleshoot, and resolve cases for participants, retirees and surviving
spouses’ pensions. Provide all facets of quality customer service through prompt call backs and answering incoming
calls. Research, create, audit, and send surviving spouses and beneficiaries’ death benefits, survivor monthly payments,
and health & welfare benefit information. Research, and resolve appeals and grievances. Contact clients to review status
of audit and benefit overpayments. Create and send letters to collect overpayments. Create spreadsheets, files, and
forms to utilize as tools of organization. Accessing the State Street Global Advisory Payroll System to verify participant
and beneficiary payments sent to them via check or electronic funds transfer; also using a second application of the
same system to verify payment status. Request stop payments, re-issue checks by use of unique application of
Wellspring Resources program. Assisted the IT department with implementing and testing new and re-configured
systems and applications to ensure quality and integrity.
Prudential Healthcare Inc., Jacksonville, Florida
December 1996 to January 1998 Job Title: Dental Member Services Specialist
Duties: Provide all facets of quality customer service through assisting, verifying, and enrollment/updating dental
membership, eligibility, and claims within a call center environment.
Verified claims information for accuracy. Reprocessed claims if errors found in original processing.
AT&T American Transtech, Jacksonville, Florida
August, 1995 to December 1996 Job Title: Benefit Specialist III/BDEC
Duties: Consist of analyzing, research, investigate, and resolution of inquiries pertaining to eligibility and enrollment of
employees, retirees, and eligible dependents. Provide customer with detailed information concerning products and
services. Determine the appropriate action required to resolve problems and coordinate resolution with employees,
retirees, or other internal/external sources. May require the calculation of data to support account adjustments. Enter
description of action taken or transaction into database. Respond to request by preparing system generated or custom
letters. Carrying the title of Case Worker, my major responsibilities were to research, investigate and resolve employees,
retirees, and dependent benefit problems. Under general supervision, respond to inquiries or process transactions of
legal, technical, or mechanical nature. Procedures to address each situation varied substantially from call to call and
were not always clearly defined for all situations. Guided by plan documents or principles of discipline.
AT&T American Transtech, Jacksonville, Florida
October 1987 to August 1995 Job Title: Customer Service Rep II/Business Services
Duties: Responsibilities included handling orders to switch, add, or enhance customers’ business’ long distance
services to and for AT&T. Research and verify long distance carriers and rates. Perform data entry duties to assure that
orders were provisioned by deadlines, also adhering to formulated script when applicable and handling fluctuating
volumes for four to five different projects while meeting productivity and quality standards.
United States Navy/AKRON 55, NAS Oceana VA Beach, Virginia
August 1983 to August 1987 Job Title: Naval Aviation Administration
Duties: Responsibilities included various government tasks, of classified and non-classified activities. Handling,
typing, filing, creating and implementing military directives, letters, correspondence and narratives which are vital to
normal operation of military commands. Obtained the title of supervisor for two years, in which I supervised 12 airmen
for various military assignments, meeting goals and deadlines. Providing standard and high security duties to secure
squadron aircraft, personnel, equipment, and documents.
Education
ROBERT E. LEE Senior High School, Jacksonville, Florida
Academics, Business Math, and Accounting / Graduated June 1983 (Diploma)
HERITAGE COLLEGE, Jacksonville, Florida
1. 900 hours Massage Therapy: Theory, Business, Practical, and Clinical Applications, Human
Anatomy/Physiology, Kinesiology, Pathology, Assessment and practice, Adjunct techniques and methods /
Graduated April 2004 (Diploma/certificate).
Special Skills
10 KEY EIP MAIN FRAME POWER POINT
1ST CHICAGO NBD PAYROLL ENTERPRISE TRANSACTION MEDICAL ASSESSMENTS RBMS
SYSTEMS MANAGEMENT
ACCESS EVT PEOPLE SOFT SEIBEL
BDS JAX, B-2000, IDCP, EXCEL MICROSOFT SUITES STATE STREET GLOBAL
ASSET, CRT ADVISARY PAYROLL
SYSTEMS
ON DEMAND
BLUE 2 FACETS SYBASE AIMSPR001 TRIZETTO
CICS GP00 NASCO C/S ULTERA FILNET CENTRAL
CLAIMS REPOSITORY IMS NETWORX CLAIMS PRICER UNIFIED NETWORK
MARX
CLIENT LETTER INTRA/INTER NET WGS CALL CARE
GARD/BPM
WSCS MCS
CONVERGENCE X ITFI ONNET 2.0 BPM
DIAMOND LOTUS PENSION PAYROLL SYSTEM WCF / WGS
I HEALTH
EBT NEXT-GEN SHAREPOINT
MEDISYS
MAS Toolbar CITRIX UPS
References Available Upon Request
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