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Customer Service Medical

Houston, TX
March 31, 2018

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ADDRESS: **** ******** ***** ***** *******, TX 77083

MOBILE: 832-***-**** OTHER: 832-***-****



Elsik High School

High School Diploma

Summary of skills:

•Advanced skills in Microsoft Office Suite including Microsoft Word, Microsoft Excel, Microsoft Outlook, Microsoft PowerPoint, Visio and Internet Explorer Key boarding skills 55 WPM / (HIPAA) / QUEST (Quality) / Advanced computer skills / Call center / Open Enrollment / Citrix / IDT / Facets / Customer service / Medicaid / Medicare / Provider Relations / Claims / Benefits / Member services / HEDIS / Grievance & Appeals / Insurance Verification / Credentialing / Medical records / Medical terminology / CPT ICD9 & ICD10 Coding and billing / IDX / Navigator / Authorizations / Macess / Epic / Facets / SAP / HRIS / plan exclusions / Case Management / Dual eligible plans

Additional Information:

•Effective strong verbal and written communication skills

•Positive, helpful approach to problem solving

•Ability to prioritize to meet deadlines

•I have previous Benefit or Insurance Customer Service experience for Medicare and Medicaid

•I also have HR Generalist experience

•Administrative duties

Work Experience:


Medical Management Specialist I

February 2017 – July 2017

•Gathered clinical information regarding cases and determined area to refer or assign case (Community Based Adult Services - CBAS)

•Provided information regarding network providers general program information when requested

•Acted as liaison between Medical Management and/or Operations and internal departments

•Prepared reports and documented all actions

•Processed Pre-service review (pre-certification, preauthorization, prospective review) for Medical and therapy services

•Insurance Verification, Concurrent review, Medical records

•Post-service (retrospective) review

•Case management


Medicare Claims/Member Service Operations

September 2015 – October 2016

•Medicare claims/benefits Specialist. Followed CMS Medicare guidelines

•Delivered Medicare Part D program health care services to members, providers, and plan sponsors also documented and tracked contacts with members, providers and plan sponsors

•Explained member's rights and responsibilities in accordance with contract. Determines medical necessity, applicable coverage provisions and verified member plan eligibility relating to incoming correspondence

•Benefits and claims examination. Escalated appropriate referrals.

•Processed grievance and appeals and pre-authorizations and claims according to client requirements

•Educated participants, on self-service options;

•Assisted providers with credentialing and re-credentialing issues

Sutherland Global Services

Veterans Affairs Consultant

October 2014 – June 2015

•Veterans Choice Program Verified coverage for veterans, set appointment, demographic updates, reissued new cards, verified and explained benefits of choice program, enrolled veterans into program as well as input and update inquires

•Created authorizations for appointments

•Set appointments for veterans to be outsourced for care

•Updated Veterans demographics

General Dynamics Information Technology

Benefit Enrollment Specialist

September 2013 – May 2014

•Utilized scripts, standard operating procedures, and training materials in responded to questions dealing with basic health care information

•Processed enrollment for Obama Care through the Affordable Care Act

•Provided knowledgeable responses to inquiries (phone, web chat, e-mail, TTY, fax, correspondence) in a courteous and professional manner

•Adhered to Privacy Act and Health Insurance Portability & Accountability Act (HIPAA)


HR Generalist

September 2011 – August 2013

• Delivered exceptional Human Resources services and solutions to the company through dedicated consultation within the HR team and our customers (Executives, Managers, and employees).

•Processed onboarding, day-to-day, and annual open enrollment benefits administration and education through HRIS management, employee relations, compensation and leave management.

•Actively worked within the HR team to insure compliance with third-party vendors and processes.

•Preparing annual EEO1 reporting – establishing data audit practices within HRIS to insure clean data is ready at time of submission.

•Processed Employment Verifications, Managing the Unemployment Claim process HR compliance tasks (I9, E-Verify, FLSA, etc.)


Administrative Assistant

September 2010 – September 2011

•Performed various secretarial/clerical duties such as documenting, photocopying, faxing, mailing, and organizing filing system

•Maintains files and calendars

•Answered telephones and transferred calls to appropriate staff members

•Sorted and distributed incoming communication data, including faxes, letters and emails

•Processing Invoices, managing other's schedules, time reporting, ordering office supplies,

•Interacted with organizational staff, executives, clients, vendors and visitors on a daily basis

United Health Care

Customer Care Professional

September 2008 – April 2010

•Provided expertise and customer service support to members regarding Americhoice Medicaid plans, benefits and coverage details

•Answered incoming phone calls from health care providers (i.e. physician offices, clinics) and identified the type of assistance the provider needs (EG. benefit and eligibility, billing and payments, authorizations for treatment, explanation of benefits)

•Focused on resolving issues on the first call, navigating through complex computer systems to identify the status of the issue and provide appropriate response to caller.

•Escalated issues, errors and trends to the Team Leader or Supervisor appropriately

•Processed caims, direct phone-based customer interaction to answer and resolve a wide variety of inquiries handles patients' questions, complaints, problems and concerns

•Explained policies and procedures to patients and refers them to the proper services required

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