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Customer Service Sales

Location:
Springfield, MA
Salary:
15
Posted:
November 22, 2016

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Resume:

** ******* ***

Apt. B

Springfield, MA *****

Phone: 413-***-****

Email: acxlqz@r.postjobfree.com

SOLMARÍ FIGUEROA-OJEDA

Professional Background

Hispanic Professional with MBA on Human Resources with more than ten years of experience in Healthcare Insurance on the Claims Department. Exceeding the production and quality requirements for more than one employee. Experience providing trainings for of the Power MHS program to the MCS Classicare (Medicare Advantage) analysts.

Education

University of Phoenix Guaynabo, PR

MBA / HUMAN RESOURCES Sep. 2009-Jan 2012

John Dewey College Río Piedras, PR

BBA / OFFICE SYSTEMS ADMINISTRATION Jan. 2007-May 2009

Job Experiences

Molina Healthcare of Puerto Rico Inc. San Juan, PR

CLAIMS SUPERVISOR II Mar 2015 – Present

Identify, interview and select candidates for employment. Track and report individual performance and attendance results. Responsible for the team achieving or exceeding performance metric target. Promote the importance of being a team player. Complete special projects, as assigned, on a timely basis. Represent department interests at internal and external functions/meetings. Accountable for accepting personal responsibility for the quality and timeliness of work assigned and assumes ownership of the results; maintains high work ethics; takes initiative to actively improve performance. Collaborates well with all levels of personnel within the company; is innovative by considering original ideas to address issues, resolve problems, and implement best practices. Provide exemplary customer service. Can take the lead in the absence of Manager to present issues and provide a potential solution. Make spontaneous decisions when required and deductive/methodical decisions where appropriate. Perform other duties as assigned

Humana Health Plans of Puerto Rico San Juan, PR

CLAIM COST MANAGEMENT PREPAY SPECIALIST Aug 2014 – Mar 2015

Work as and Prepay Specialist Auditor for Humana Medicare and Commercial Products for the United States Market. Processing claims as: Hospital Services (Inpatient & Outpatient), Home Health, Laboratories, X Rays, Visits, Anesthesia, and Multiple Surgeries among other types of services. Managing the variety of laws for each state and the products that Humana have for each state as well. With a production level of 60 claims per day.

Triple S Advantage / American Health Medicare Guaynabo, PR

PROFESSIONAL CLAIMS ANALYST (TRIPLE-S) Jan 2013 – Aug 2014

Processing payments and adjustments in professional claims of Triple-S Medicare and its products, Optimo and Selecto. Claims such as: prosthetics trays, Emergency Room Visits, Laboratories, X rays, high cost claims and United States Claims.

Exceeds the productions limits by 25% (250 of 200 regular claims) and 20% (120 of 100 adjustments).

Humana Health Plans of Puerto Rico San Juan, PR

OPERATION SUPPORT Jan 2011 – Dec 2012

Fax administrator for the Case Management Department cases.

Documents management and organization, make calls and organizing referrals received for surgeries and prosthetics trays. Coordination and management of the cases of prosthetic trays to be authorized by the Nurse (RN). Make reports and other clerical responsibilities. Good understanding of communication with outside vendors and suppliers of Humana network.

Medical Card Systems San Juan, PR

CLAIMS ANALYST III, SENIOR June 2000 – April 2003 / Aug. 2005-Dic. 2008

Processing of payments and adjustments of Hospital claims, COB, Emergency Room visits, Home Care, medical visits, laboratories, DME among others.

Exceed productions requirements by 11% (500 of 450 adjustments).

Provided trainings of Power MHS program to the MCS Classicare analysts; among five to six groups during a one year period.

Spanish Broadcasting System Guaynabo, PR

ADMINISTRATIVE, SALES AND PROGRAMMING ASSISTANT April. 2003-Aug. 2005

Administrative support for the General Managers and Vice President of Programming Music Stations: such as: MEGA, ONDA, CIMA, ESTEREOTEMPO & Z-93. Writing letters, memos, taking care of stations public files.

Administrative support for the Departments of Direct Sales and Agency Sales. Coordination and management of sales contract of Agency Sales Department. Organization and control of Radio Spots and announcements and data entry of the same in the system.

Coordination of the recording process of the spots and post-production of the ones that was too long to make. Control of the invoicing process for the clients of the stations. Managed of the office of the Programming Director of Z93.

Writing and handling of contracts for the rent of film studies in the station.

Student & Professional Organizations

Active member of: National Society of Hispanic MBAs (NSHMBA), Phoenix Alumni, Hispanic Organization for Leadership & Achievement (HOLA), Society For Human Resource Management Puerto Rico Chapter (SHPR)

Skills and Qualifications

Working with computers and their software’s like Windows. Also excellent knowledge in the use of Microsoft Office, Power MHS, JWalk, Mainframe, View Client, ADP, Encoder Pro, ASC, EZCAP, CCMS, QNXT, Medical Management (PROTON) and RIMS. Excellent handling of office equipment. Knowledge and management of CPT Codes, HCPCS codes, ICD-9 and ICD-10. Good interpersonal relationships and Bilingual (Spanish and English).



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