Dedicated customer service escalations manager with proven supervisory experience and industry knowledge, seeks position in call center setting where my skills will be an asset.

QUALIFICATIONS SUMMARY

●Strong team leader who knows how to establish unit goals and motivate others to exceed client and company expectations.

●Dedicated and hardworking, with an unmatched drive to produce results.

●Unparalleled customer service knowledge and acumen.

●Government security Clearance

●Over 10 years of experience in Operations in varying roles. From Load Planning for an Industry Leader or in a medical claims environment, where I handled medical claims as well as trained new adjusters to process claims in a call center environment, while employed with one of the largest Health Insurance providers in the United

States.

●Extensive knowledge of Medicare, Medi-Cal and Health Insurance claims. Also ICD-10, CPT-5, HCPCS,DRG coding and experience in the processing of Medicare/ MediCal and Health Insurance claims. Proficient in all MS Office applications.

●Proficient in AS400, UNET, DIAMOND System, Tiny Term, MediTech, OneSource, MyQNXT, QNXT and Health Connect and WPS systems.

●Proven ability to train medical claims adjusters to a very high level of claims adjudication accuracy.

PROFESSIONAL EXPERIENCE

Operations Trainer (8/22-11/23)

Network Health, Inc - Menasha, WI

Delivering, measuring and facilitating training across multiple facets of call centers. Facilitated training across multiple needs.Trained Call Center Representatives and Transaction AssociatesTraining on various technical subjects with the development of curriculum as needed.

Helped develop a new curriculum company wide.Received multiple awards for excellence in training development.

Humana Military, Louisville, KY (Remote)

Executive Escalations Consumer Experience Professional 2 (11/2018 - 5/2022t)

Handle executive level escalated issues.

Work with grievances and appeals to get issues completed

Process in real time, root cause analysis for incoming and existing issues.

Act as a liaison between governmental agencies and beneficiaries

Manage clams data between Humana government and the Defense Health Agency

Provide assistance to both civilian and military health partners in the processing and correct handling of claims data

Manage incoming escalated inventory that is coming from the field, including line of duty claims

United Healthcare, Green Bay, WI

NPSR Escalation Specialist (7/2017-11/2018)

Handle escalation calls from floor agents. Own and resolve all issues that are presented. Assist claims processors both Large group and small group business as tier 2 subject matter expert. Trained to process underpayments and medicare claims.

United Healthcare, Green Bay, WI

Benefit Advocate (11/2016-7/2017)

Assist members with selecting the best benefit plan options available to them through the enrollment process, including enrollment in specialized care programs

Resolve member service inquiries related to:

Medical benefits, eligibility, and claims

Financial spending accounts

Pharmacy benefits, eligibility, and claims

Correspondence requests

Educate members about the fundamentals of consumer-driven health care including:

Managing health and well being

Maximizing the value of their health plan benefits

Choosing a quality care provider

Premium provider education and steerage

Own problem through to resolution on behalf of the member in real time or through comprehensive and timely follow-up with the member

Schneider National, Green Bay, WI

Van Truckload Operations Support (11/2013 – 2/2016)

Assist all Independent Contractors with load planning and removing loads if necessary. Resolve all issues and assist drivers with day to day operations. Communicate with various customer groups and logistical clients to ensure on time time delivery. Track and maintain interdepartmental systems.

Primary Provider Management Company, Inc, Corona, CA

Claims Examiner III / Provider Call Center (7/2013 - 10/2013)

Processed Medi-Cal, Medicare and Commercial Plan claims with 98% Accuracy. Respond to complex Provider calls,

Resolve customer service inquiries which could include:

Benefit and Eligibility information

Billing and Payment issues

Provider material requests,

Physician assignments,

Authorization for treatment and

Explanation of Benefits/Remittance Advice inquires.

Provide excellent customer service

Constantly meet established productivity, schedule adherence, and quality standards.

Inland Empire Health Plan, San Bernardino, CA

Provider Call Center Representative (4/2013 - 7/2013)

Respond to complex Provider calls,

Resolve customer service inquiries which could include:

Benefit and Eligibility information

Billing and Payment issues

Provider material requests,

Physician assignments,

Authorization for treatment and

Explanation of Benefits/Remittance Advice inquires.

Provide excellent customer service

Constantly meet established productivity, schedule adherence, and quality standards

Inland Empire Health Plan, San Bernardino, CA

Claims Quality Assurance Trainer (9/2011 - 4/2013)

Train the Quality Assurance, Claims Production, Appeals Resolution, and temporary staff on the most current regulations for Medi-Cal and Medicare processes. Develop training curriculum to fit the needs of the department as a whole. Train new hire and existing staff members on MRMIB,DHCS,CMS processes. Run Daily Audit reports. Track trends within the unit.

Kaiser Permanente (Contracted by Rose International, Inc), Moreno Valley, CA

Admitting Clerk (6/2011 - 4/2012)

Tracked all patient admissions within the emergency department. Verified all insurance types, including Medicare, Medi-cal and all Commercial insurances. Kept all admitting paperwork orderly and accurate for the hospital billing department. Monitored daily hospital census of inpatient and outpatient discharges.

United Health Care, Green Bay, WI

Operational Trainer (2/2008 - 12/2010)

Delivering, measuring and facilitating training

Training Call Center Representatives and Transaction Associates

Training on various technical subjects

Assisting with the development of curriculum as needed

Experience working as a claims rep associate, claims processing/adjusting, or a background working with medical insurance or employer benefits

Proficiency in Microsoft Office applications

The ability to teach and present to others

Experience training others

Experience working in the health insurance industry

●Received SPOT award for best CPI Index score for the first quarter of 2009 and 2nd quarter of 2010.

●Spearheaded the use of a new operating system for call and claims. Integrated System Enhancement Tool.

●Received multiple awards for excellence in training development.

United HealthCare, Green Bay, WI

Health Advisor (7/2007 - 2/2008)

Assist members with selecting the best benefit plan options available to them through the enrollment process, including enrollment in specialized care programs

Resolve member service inquiries related to:

Medical benefits, eligibility, and claims

Financial spending accounts

Pharmacy benefits, eligibility, and claims

Correspondence requests

Educate members about the fundamentals of consumer-driven health care including:

Managing health and well being

Maximizing the value of their health plan benefits

Choosing a quality care provider

Premium provider education and steerage

Own problem through to resolution on behalf of the member in real time or through comprehensive and timely follow-up with the member

Help members navigate myuhc.com and other UnitedHealth Group websites by co-browsing and locating information online with the member

Intervene with care providers on behalf of the member

Research complex issues across multiple databases and work with support resources to resolve member issues

Assist members with provider appointment scheduling

Connect members with internal specialists for assistance when needed

Partner with Appeals Coordinator to resolve escalated issues

Provide education and status on previously submitted pre-authorizations or pre-determination requests

United Heath Care, Green Bay, WI

Customer Care Professional (2/2007 - 7/2007)

Respond to complex customer calls

Resolve customer service inquiries which could include:

Benefit and Eligibility information

Billing and Payment issues

Customer material requests

Physician assignments

Authorization for treatment

Explanation of Benefits (EOB)

Provide excellent customer service

Constantly meet established productivity, schedule adherence, and quality standards

Loomis and Fargo, Green Bay, WI

Armored Guard (6/2006 - 2/2007)

Ensured safe delivery and pick up of money transportation. Maintained accurate data in transfer of money to clients

●Performed the work previously required of two full-time employees

Imperial Supplies, Green Bay, WI

Sales Representative (12/2005 - 5/2006)

Maintained exsisting account base while expanding to different account holders.

Suncoast Motion Picture Company, Riverside, CA

Assistant Manager (8/2003 - 12/2003)

Maintained store operations and provided customer service on a daily basis. Communicated with vendors and companys to maintain stock on shelves and promational materials in store.

●Managed team of four part-time and nine full time employees

●Established and maintained clean, professional and profitable retail outlet location

●Developed new method of stocking shelves resulting in a 25% time savings when receiving weekly deliveries

Toys R Us, Riverside, CA

Sales Rep (10/2002 - 2/2003)

Supervised back room operations and monitored shipping and receiving. Compiled daily reports to show efficeincy of orders.

US Army, Various, Various

Avenger Crewmember (7/1997 - 4/2002)

Operated multi million dollar weapon system.

●Received 1 Army Commendation Medal, 2 Army Achievement medals, 2 Army Good Conduct Medals and 1 National Defense Medal.

EDUCATION

University of Phoenix, Murietta, CA

2013 - Current

30 credit hours from completion - Riverside Community College, Riverside, CA

2003 - 2005

Fort Bliss Air Defense School, El Paso, TX

1997

Ramona High School, Riverside, CA

1997

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