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Customer Service Office Staff

Hialeah, FL
October 12, 2018

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Lissett Alvarez

**** * ** ** *******, Fl. *****

Phone # 305-***-****


To obtain a position with a growing company where I could utilize my skills to the best of my ability.


I am oriented self-motivated professional, having 15 years of diversified experience in the managed care industry. In my years of experience as a member service specialist I have developed a great rapport with members and providers of care alike:

My skills experiences include:

* Coordinating care and services for members.

* Interface with primary care physicians and staff.

* Serving as liaison between the members and the company.

* Coordinating referrals with specialist and hospitals, resulting in retaining happy members in the health plan.


2012-2017 Sheridan Healthcare Corp. Sunrise, FL

ED Reimbursement Specialist III

● Run reports on specific providers or insurance that may have an outstanding AR over 30/60 or 90 days pending any payments and no response from insurance company.

● I would also ensure my team was update with their correspondence or their grid

● Adjust any accounts if necessary

● if any payments were posted incorrectly forward them to the payment posting department to have the correction made.

● Have weekly huddled with the team to inquire if they had gathered any new information pertaining a payor, any new issues, discrepancies

● Biweekly meetings with management to discuss any new issue update on A/R

● Researches all assigned contracted and/or non-contracted carrier and self-pay accounts to ensure the proper payment through reports, spreadsheets and special projects as deemed necessary.

● Processes correspondence related to assigned contracted and/or non-contracted carriers including self-pay accounts.

● Maintains denial reports and ensures accounts are properly documented.

● Responds to customer service calls and strives for one time resolution of accounts received.

● Researches denied and improperly processed claims by contacting assigned carriers to ensure proper processing of said claims.

● Resubmits improperly paid/denied claims to the carrier for proper payment in a timely manner.

● Identifies and corrects any claim processing errors due to data entry, verification, coding and/or posting mistakes. Ensures accounts are properly documented.

● Call and check claim status, work A/R and insurance carrier reports, and insurance denials

● Handle and organize all aspects of the appeals process for all insurance payers

(letters, phone calls, special projects from carriers).

● Interface with front office staff regarding insurance/patient issues 2008- 2012 American Ambulance Miami, FL


* Document the denial's the insurance companies send for the patients

* Appeal the denial's

* Correct the claims and resubmit them

* I am in charge of the Treasure Coast Region and I handle all the Insurances Blue Cross, Cigna, United Health Care, Care Plus, Staywell, Well Care, Medicaid, Magna Care, Aetna,

* Customer Service

* Answer the patient's questions pertaining their claim

* Explain to the patients how they may appeal a claim

* Verify coverage for the patients thru Emdeon or Availity also contacted the facilities or the patients for information

2007-2007 MD Medicare Choice/ Partner Care Health Doral, FL Enrollment Specialist

* Received new Medicare applications on a daily basis

* Reviewed applications to make sure they were completely filled

* Reviewed information in the CMS system before entering

* Enter applications in the system

* Forward all original applications to the Corporate office via Fed Ex on a daily basis

* File copy of the applications

Marketing Coordinator

* Planning and forecasting short and long term objects

* Set up daily and weekly visits for participating providers

* Maintained daily contact with the assigned physicians

* Weekly staffing with marketing supervisor for updates on all marketing activities

* Insure that all marketing materials are in place at the providers office

* Responsible of development for the marketing

2005-2007 Sun Coast Health Plan Weston, FL

Provider Relations Supervisor

* Maintained and coordinated timely communication between the providers and the health plan by routinely meeting and communicating with providers and their office staff

* Ensured that all network providers understood the health plan's policies, procedures, and contractual obligations

* Established and promoted provider satisfaction by maintaining an open exchange of information by soliciting provider feedback for continued quality improvement and retention of network providers

* Resolved provider/member complaints, claims issues, and grievances in a timely manner

* Collected necessary information(i.e., site visit form, re-credentialing applications, supporting documents, etc.) as requested by the Credentialing department

Customer Service Supervisor

* Supervise a staff of Customer Service Representatives to ensure prompt responses to member inquires and complaints

* Delegate, plan, and organize duties of Customer Service staff

* Confirm process flow is followed and is within CMS guidelines

* Oversee enrollment and disenrollment processes

* Contribute to the going integration of Customer Service by identifying opportunities for quality and process improvements 2003-2005 Vista Health Plan Hollywood, FL

Special Service Representative

* Retained members on the plan

* Welcomed members to the plan

* Contacted members to participate in orientations as well as set up location, dates and plans for large events throughout Southern Florida 2001-2003 Care Plus Health Plans/Physicians Healthcare Coral Gables, FL Customer Service

* At Care Plus Health my duties were to service the members with changing their primary physicians at their request. Assisted patients with choosing a healthcare specialist and resolving referral issues. In addition, I provided members, providers’, hospitals, pharmacies and skilled nursing facilities with eligibility and benefits.

1999-2001 Americatel Corporation Doral, FL

Customer Service Specialist

* At Americatel, my duties included effectively monitoring trouble tickets from Americatel clients for V-SAT, IBS & Internet Services. Also, provided efficient maintenance support for private code such as 1010123. I worked as a team player while troubleshooting, monitoring discrepancies within Americatel fraud department.

1991-1998 CAC Ramsay

Receptionist/Cashier Miami Lakes, FL

* At CAC Ramsay my responsibilities were to greet the patient, answer the phone, schedule appointments and medical records. I was also responsible to receive the monthly premium payment and also receive the co-payments of the patients. I also worked in the medical records and referral department.


2005 Florida Career College Hialeah, Fl.

* Completed Medical Billing & Coding Program

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