Customer Service Representative
Resume:
MARISA ROBLEDO
**** * *** *** ********, CA ***** 661-***-**** ********.***@*****.***
Claims Analyst professional is seeking a position within a challenging setting; works well with others and within a team environment, meeting and/or exceeding departmental goals and expectations. Quickly learns new processes and procedures, thrives in challenging settings, using good judgment and exhibiting sound problem solving skills.
Summary of Qualifications:
10+ years of call center experience
Keen eye for detail, demonstrates strong researching skills
Can quickly determine customer needs and respond accordingly
Work Experience:
Health Net Woodland Hills, CA
Claims Analyst 06/06/16 to Current
Demonstrates regular, reliable and predictable attendance.
Researches/adjusts all difficult, complex requests for overpayment, underpayment, refund, contract issues, and stop loss to ensure compliance with departmental and company policies and procedures. Conducts cost containment analyses.
Processes all adjustment issues, as they occur to comply with company service standards and to ensure achievement of company goals.
Determines level of reimbursement based on established criteria: contracts, plans, and employer groups. Coordinates special payment agreements with providers based on contract terms.
Maintains and updates knowledge of all claims products, contracts and standard reference materials.
Develops and maintains effective business relationships with internal and external clients. Negotiates in settlement of claims when necessary.
Ensures compliance with government regulations and requirements (NCQA, DOC, HCFA).
Performs special projects as assigned.
Health Net / Kelly Services Woodland Hills, CA
Customer Service Representative II 07/14 to 06/05/16
Take inbound calls
assist members with PCP Appeals & Grievances
handle complaints
transportation
Provide excellent customer service to the members.
Assist member switch health plans, PCP transfers.
Provider services for claims, appeals, and eligibility.
Arvato Digital Services Valencia, CA
Customer Service Representative 11/09 to 09/10
High volume of inbound and outbound phone calls
Email creation and responses
Website navigation
System override
Inter-department assistance
First American Home Buyers Protection Van Nuys, CA
Claims Advisory Representative 01/09 to 09/09
Managed all Supervisor Calls
Case Management
Data Entry
Investigated Homeowners claims for compliance
Collection Service Bureau Scottsdale, AZ
Medical Collector 07/06 to 12/06
Collection calls to past due clients
Payment arrangements
Case Management
Data Entry
Education:
Antelope Valley Community College Lancaster, CA
Associates Science: Liberal Arts & Behavioral Sciences 2013
Associates Arts: Administration of Justice 2012
Cal State Bakersfield Lancaster, CA
Bachelor’s: Criminal Justice Current
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