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Customer Service Medical

Canoga Park, California, United States
November 08, 2018

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***** ******** **, ********, ** 91306 H: 818-***-**** Energetic and enthusiastic insurance professional motivated to succeed in a fast-paced and deadline- driven professional environment. Comprehensive knowledge of benefit, authorizations requirement and appeal process.

Microsoft Office Suite

Conflict resolution proficiency

Proficient in customer account

High customer service standards


Strong problem solving ability

Hedis calls done 8 years for


positions at Anthem Blue Cross.

administrative, Conflict resolution,

customer service, fashion, letters,

logging, mailing, Medical

Terminology, Microsoft Office

Suite, pick, policies, problem

solving, speaking, quality

assurance, recording, script,


Hedis 2018 Measure Trained

Hedis 2018 Abstracting and


11/2017 to 04/2018 Hedis Reviewer 2- Aetna Contract Integrated Resources, Inc - Woodland Hills, CA

Contacted providers by phone to obtain Medical Records. Abstracted Hedis 2018 Measures to Medical Records received. Researched Medical Records for Compliance and Non-Compliance. Quickly learned updated Hedis 2018 Measures from online training. 05/2017 to 10/2017 Appeals and Grievance Triager, Centene/Health Net - Woodland Hills, CA Addressed customer service inquiries in a timely and accurate fashion. Formulated and enforced Service Center policies, procedures and quality assurance measures.

Built customer loyalty by placing follow-up calls for customers who reported product issues.

10/2015 to 03/2017 Utilization Management Coordinator Anthem Blue Cross - Woodland Hills, CA

Created denial letters and mailed to providers in a timely matter. Made outbound phone calls to providers giving denial information. Kept records of customer interactions or transactions,recording details of inquiries, complaints or comments as well as action taken by using the EDUCATION AND TRAINING


WMDS software.

09/2008 to 10/2015 Health Program Representative SR Anthem Blue cross - Woodland Hills, CA

Coordinate communication between patients, family, members with the Health Plan and its medical advisors.

Maintain knowledge of community services and resources available to the members.

Explain policies, procedures, or services to patients using medical or administrative knowledge.

Trained a team of 10 to follow script while speaking to members and providers.

09/2006 to 09/2008 Bipolar Outreach Specialist

Anthem Blue Cross - Thousand Oaks, CA

Made outbound phone calls to members to remind them of missed pick up medication.

Assisted members by mailing community resources in their area. Keep records of members interactions,or transactions by logging all calls by members and providers.

Reviewed all reports for accuracy of medications by contacting members for any update.

06/2005 to 09/2006 Medicare Part D / Enrollment Representative Anthem Blue Cross - CA

Received inbound calls assisting members by enrolling them in the correct plan that best matched them.

Provided members with community services and other resources helpful to them.

Trouble solved irate members calls that came in through the escalated line.

1979 High School Diploma: English

West Side High - Gary, Concordia Ann Arbor, IN, MI, United States Activities and Honors Volunteer-North Hollywood Feed the Homeless Program Medical Terminology Certificate-Pierce College

Accident and Health Agent

Life-Only Agent

License # Will be supplied when needed.

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