Sign in

Customer Service Insurance

San Diego, California, United States
May 19, 2017

Contact this candidate


**** ******** ***, *** *****, CA 92120-4812

(619) ***-**** ~ FAX: (619) ***-**** ~ E-mail:

OBJECTIVE: Seeking a position that uses my extensive experience in customer service and resolution of simple and complex claims issues.

EDUCATION: B.A., College of Letters & Science, University of California, Berkeley.

COMPUTER: Proficient in: Word Perfect, Microsoft Office, Microsoft Word, PowerPoint and Excel.

SKILLS: ● General: During my long career in the health insurance and managed health care industries, one of my responsibilities was customer service, including claim resolution. With the onset of managed health care I began designing health plans for insurance companies, Taft-Hartley Union Health Plans and employer self-funded plans. As it was my plan design, I became the final authority for interpreting the policy and handled all complex eligibility and claims issues. These opportunities to design medical (also dental) health plans occurred because I was a pioneer in building provider networks (which five years later became known as Preferred Provider Organization or PPOs. All provider contracts were owned by my company, Raffetto & Associates, Inc., which meant that all of my clients could use the same provider contracts. I also took on the responsibility to provide clients with the language suitable for amending their filings with various Departments of Insurance and Department of Labor. This wide field of endeavors allowed me to become highly effective in customer service and claims resolution.

● Blue Cross of Southern California: I worked as a Sales and Service Representative in the Orange County, CA office. On my first day, I removed 10 medical claims from my in-box; some unresolved for over a year. I had to work through the multi-layered corporate structure of Blue Cross before closing out many of those claims. The last of the 10 claims was from my Kimberly-Clark account. I knew Blue Cross of So. Cal. administered the medical insurance policy, but it was written by Wisconsin Blue Cross, Kimberly-Clark's headquarters. The Wisconsin policy did not fully align with medical policies sold in Southern California, which created the claim problem. I had to contact Wisconsin Blue Cross before the matter could be resolved. Had I not gone “outside the box” by calling Wisconsin Blue Cross, I would not have been able to resolve that claim.

Family Health Program (FHP): I was hired as a sales manager for this HMO and given a territory and all accounts therein, which included many of the same city governments and school districts I had worked with during my time with Blue Cross. FHP owned an insurance company, Health Maintenance Life (HML). When FHP introduced a medical plan with two separate options, One the HMO and the other a traditional medical insurance plan through HML, it became my job to market this plan. The FHP/HML plan contained the first health plan in the U.S. to require prior authorization before elective hospital admissions were covered. I told prospects that prior authorization put the FHP/HML plan on a par with Blue Cross. The authorization procedure meant that plan members never had any delay upon arriving at the hospital –something Blue Cross was famous for. What is noteworthy here is that throughout my career I have been a problem-solver and innovator.

I was a pioneer in stabilizing health plan claims cost by putting health providers under contract and then causing plan members to seek care from those providers. I also pioneered a successful provider-friendly utilization management system that did not second-guess physicians and could review large volumes of outpatient claims in 72 hours or less. My PPO became largest privately owned in the US. My innovations in marketing, benefit administration, provider relations and customer service impacted administrators (TPAs), labor unions (Teamsters, O.P.E.I.U.) and insurance companies (New York Life’s Empire Trust, California Life and Washington National.

● Customer Service: Certainly, I have command of virtually all employee benefit plans. To achieve this I first review limitations and exclusions of the policy. While I take pride in the number and quality of my sales, I’ve also taken servicing my clients as an equal responsibility. I am well versed in the customer’s rights under California’s Health & Safety Act, however before seeking regulators’ assistance I usually can settle customer issues through negotiation and compromise. My objective is to resolve disputes within 10 working days.

JOB HISTORY: 1995 – Date (except 02/03 – 06/04 and 01/05 – 06/09): Self employed Managed Health Care Consultant.

2/03 - 6/04: Employee Benefit Manager and analyst for Universal Financial Consultants (San Diego, CA)

01/05 – 06/09: Senior Plans’ Sales Representative for Anthem Blue Cross

1985 - 1995: Founder/Co-Owner of EMGIS Insurance Services, Inc. (Pleasant Hill, CA)

1986 – 1995: Founder/CEO of ConserviCare, a California PPO.

MILITARY: Served 4 years + in the U.S. Air Force Special Intelligence with top secret codeword clearence. I had two deployments overseas, first to Japan; second to Peshawar, West Pakistan and was honorably discharged

Contact this candidate