Customer Service Data Entry

Solmarí Figueroa-Ojeda

PROFESSIONAL SUMMARY

Highly skilled and personable customer service and data entry professional with over ten of experience in high volume businesses especially in healthcare insurance on the claims department. Detail oriented with ability to multi-task, experience working in a professional office environment, knowledge of office equipment, knowledge & management of CPT Codes, HCPCS codes. Bilingual (Spanish and English)

SKILLS

MS Windows, MS Office, Power MHS, JWalk, Mainframe, ASC, EZCAP, WinRisk, TPP, Polaris, ECM, CCMS, Medical Management (PROTON), RIMS, QNXT, CPT Codes, HCPCS codes, ICD-9 and ICD-10

PROFESSIONAL EXPERIENCE

AETNA, HARTFORD, CT Dec 2017 – Present

Senior Claim Benefit Specialist

Reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with claim processing guidelines

Reviews pre-specified claims or claims that exceed specialist adjudication authority or processing expertise

Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment measures to assist in the claim adjudication process

Processing will occur on a DOS operating system (DG claims system)

Minimal 200 claims per day while maintaining 99.8% quality.

ROSE INTERNATIONAL, MO Jul 2017 – Dec 2017

Healthcare Consultant 1

Reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with claim processing guidelines

Reviews pre-specified claims or claims that exceed specialist adjudication authority or processing expertise

Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment measures to assist in the claim adjudication process

Processing will occur on a DOS operating system (DG claims system)

Minimal 200 claims per day while maintaining 99.8% quality.

MASS MUTUAL FINANCIAL GROUP, Springfield, MA April 2017 – Jun 2017

Customer Service Specialist

Provides a variety of services to policyholders, insureds and/or their financial advisors, field force and home office staff. Performs routine transactions and provides technical guidance, and procedural information on a variety of customer service issues. Limited knowledge of product features and transaction processing. Typically, an entry level position.

SPRINGFIELD HOUSING AUTHORITY, Springfield, MA Dec 2016 – April 2017

Office Clerk

General office work, take calls, attend residents for the District E of Springfield Housing Buildings.

MCLAUGHLIN PAPER CO. / GENEVIEVE’S FUNDRAISING, Springfield, MA

Oct 2016 – Dec 2016

Data Entry

Received, identify and make the data entry of the fundraising order that we received on Genevieve’s.

Log in the received orders and prepared the mailing for the customers.

MOLINA HEALTHCARE OF PUERTO RICO INC., San Juan, PR

Mar 2015 – Oct 2016

Claims Supervisor II

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 Aug 2014 – Mar 2015

Claim Cost Management Prepay Specialist

Work as a 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.

AMERICAN HEALTH MEDICARE, Guaynabo, PR Jan 2013 – Aug 2014

Professional Claims Analyst (Triple-S)

Processing payments and adjustments in professional claims of Triple-S Medicare and its products, Óptimo 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 Jan 2011 – Dec 2012

Operation Support

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

Jun 2000 – Apr 2003 / Aug 2005 - Dec 2008

Senior Claims Analyst

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 Apr 2003 - Aug 2005

Administrative, Sales and Programming Assistant

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.

EDUCATION

MBA / Human Resources

University of Phoenix, Guaynabo PR, Sep 2009 - Jan 2012

BBA / Office Systems Administration

John Dewey College, Río Piedras PR, Jan 2007- May 2009

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)

Contact this candidate