Medical Insurance

Zinaida Tsizer

**** ******* ******, #***, ******, CA 91316 ********@***.*** (818) 599-

7454

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~ Customer Care Specialist - Senior Administrator ~

Claims and Membership administration

Claims Auditing

Trustee / Proxy administration

Resume Highlights

( Contract interpretation ( Coordination of Benefits

( Information and document gathering and control ( Juris Doctorate,

completed first year

( Information extraction from multiple systems ( Bachelor of Arts

in Political Science

( Legal internships with practicum ( Bilingual (English and

Russian)

Formal Education:

Juris Doctorate, Glendale University College of Law, Glendale, CA,

Completed first year

Bachelor of Arts in Political Science, California State University

Northridge, Northridge, CA, 2007

Associates of Arts in Liberal Arts, Los Angeles Pierce Community College,

Woodland Hills, CA 2005

Associates of Science in Business Management, Massachusetts Bay Community

College, Wellesley, MA, 1999

Legal Internships: (1/2007 to 5/2007)

NLS - LA: Assisted Pro Per clients with paperwork for family law matters

(dissolutions and custody), domestic violence, and unlawful detainers

(evictions).

CSU, N Judicial Internship: A legal internship that allowed access to all

parts of the court (public and private), followed by a summation to

contrast and compare the reality of the court system with the written

ideals.

Experience:

Customer Care Associate

WellPoint/Anthem Blue Cross, Newbury Park, CA

04/2009 - 01/2013

WellPoint/Anthem Blue Cross, Woodland Hills, CA through Superior Group

10/2008 - 01/2009

. Interpret contracts (private and group insurance policies - HMO, PPO,

EPO and POS), company policies and company procedures to address

concerns

. Use a variety of systems and in collaboration with other departments

to resolve member, provider, group administrator and broker concerns

. Was a Lead (assistant manager) to an off-site location to input and

process data and resolve all escalated calls

. Researched and would send out to correct / reprocess / adjust claims

based on: if claims were for facility or professional services; global

or regular services; code and/or modifier designations; researching

medical records and/or superbills; if the line items should be bundled

or unbundled depending on the services received; if the providers were

in or out of network; depending on the deductible, copays, coinsurance

percentages, and the current state of the maximum out-of-pocket amount

paid out by the members

. Filed regular and emergency Grievances and Appeals to get benefits and

services covered and/or expedited

. Filed Out-of-Network requests and referrals to obtain needed services

. First point of customer retention and up-selling of policies

. Operated a large variety of proprietary and Microsoft based office

systems to: obtain, extract and input and correct information; to

document information, activities, changes in the database, and

tracking to troubleshoot issues and for analysis purposes

o Systems Used: Imaging systems (FileNet, Ultera, MAS Toolbar,

CIRS and Framework Content) to locate claims, all written

correspondence and to retrieve selected HIPAA rights; Data

and processing system (STAR/Mainframe and UNNMS) to maintain

member data, access underwriting and broker records; Payment

systems: STAR to process credit card payments: WebToCash

system to process check payments; CSI Console to process

check and credit card payments; RightFax and Outlook to

retrieve and dispense faxes; CallCare Browser to get medical

benefit information and Explanations of Coverage and

exclusions, claims history including rejections and

accumulator information, Explanation of Benefits information

as well a line items, and to update regular and statistical

data regarding medical information; Compass to retrieve

pharmacy benefits, look up history, run test claims, and

obtain prescription pricing; and used and manipulated

SharePoint to create and store all legal documents and

correspondence

In-Home Support Services

05/2000 - 01/2012

Los Angeles County, CA

. Conducted and oversaw all financial, medical, and legal affairs as a

trustee

. Filed medical claims in collaboration with medical providers and

insurance companies

. Scheduled and coordinated all appointments, medical care, and

financial activities

Investigator/Accounts Receivable Representative

01/2000 - 10/2001

Primax Recoveries, Inc., Calabasas, CA

. Collected and verified documentation of people's insurance based on

past paid medical claims then input the data into a data tracking

system that started a collection process for overpayments on past paid

claims

. Applied collected data to Coordination of Benefits guidelines between

federal (Medicare), group, private insurances and state / county

(Medicaid) programs

. Training coordinator - assisted management with training new employees

REFERENCES FURNISHED UPON REQUEST

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