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

Sunrise FL *****

954-***-****

adqcla@r.postjobfree.com

Ivan Cintron

Objective

A challenging career that will utilize my exceptional skills. Where my experience and abilities will result in an improved organizational productivity and contribute to a company’s success.

Experience

10/2021-Present Teleperformance North Lauderdale, FL

Customer Service/Provider Claims

Handle inquiries from members and providers regarding claims, eligibility and covered benefits

Review claims to see if processed correctly and send to be reprocessed if incorrect

Handle and carefully respond to all customer inquiries by building excellent rapport & confidence, identifying their needs, and taking strategic action in a timely manner

Provide excellent customer service through active listening on every interaction

Troubleshoot and resolve issues on the first call by being proactive and demonstrating advanced product knowledge

Work with confidential customer information and treat it sensitively

Provide assistance to members and/or providers regarding website registration and navigation

07/2017-07/2020 Sunshine Health Sunrise, FL

Member Advocate

Receive and respond to Member complaints and formal grievances and identify potential access barriers and resolve as indicated in the grievance procedure

Solve daunting member problems with research, intellect, grit, and most importantly, empathy

Collaborate across the Member Services department to find strategic solutions to member pain points

Investigate and resolve access and cultural sensitivity issues identified by Member Services staff, State staff, providers, advocacy organizations and recipients

Serve as primary contact for Member advocacy groups, human services agencies and the State entities

Maintain confidentiality per HIPAA guidelines

07/2016-07/2017 Sunshine Health Sunrise, FL

Customer Service

Resolve customer inquiries via telephone and written correspondence in a timely and appropriate manner

Reference current materials to answer escalated and complex inquiries from members and providers regarding claims, eligibility, covered benefits and authorization status matters

Provide assistance to members and/or providers regarding website registration and navigation

Educate members and/or providers on health plan initiatives Provide first call resolution working with appropriate internal/external resources, and ensure closure of all inquiries

Document all activities for quality and metrics reporting through the Customer Relationship Management (CRM) application

Process written customer correspondence and provide the appropriate level of follow-up in a timely manner

Identify trends related to member and/or provider inquiries that may lead to policy or process improvements that support excellent customer service and impact quality and performance standards

Work with other departments on cross functional tasks and maintain performance and quality standards based on established call center metrics including turn-around times

01/2016-07/2016 Aerotek Sunrise, FL

Member Services

Respond to telephone or written correspondence inquiries from members and/or providers within established timeframes utilizing current reference materials and available resources Assist beneficiaries with updating account information, providing plan information

Provide assistance to members and/or providers regarding website registration and navigation

Document all activities for quality and metrics reporting through the Customer Relationship Management (CRM) application

May coordinate member transportation and make referrals to other departments as appropriate

Maintain performance and quality standards based on established call center metrics including turn-around times

Research and identify any processing inaccuracies in claim payments and route to the appropriate site operations team for claim adjustment

Identify any trends related to incoming or outgoing calls that may provide policy or process improvements to support excellent customer service, quality improvement and call reduction

10/2014-11/2015 Convey Health Deerfield Beach, FL

Customer Service

Receive inbound calls from various Over-the-Counter clients and beneficiaries enrolled into a program

Assist with updating account information, providing plan information

Educate beneficiaries on how the plan works, including benefits, cost sharing and levels of coverage

Resolve issues with utilization of the plan, and take new orders or reorders for products sponsored by the plan such as OTC items

Answer all billing questions and claim questions

Research premium billing discrepancies and prescription claims processed

Submit mail requests for beneficiaries such as ID cards and Formularies

Educate beneficiaries on how the plan works, including benefits, cost sharing and levels of coverage

Respond promptly when returning telephone calls and replying to correspondence and faxes

Assist Pharmacies with prescription denials and errors and verifying benefits.

Advise providers on how to get prior authorizations on medicines prescribed with restrictions such as step therapy and quantity limits

02/2013-01/2014 UNIVITA Miramar, FL

DME Equipment Recall Coordinator/Appeals Coordinator

Assist with inter-departmental duties dealing with Billing, Purchasing, and Dispatch.

Respond to all departmental correspondence.

Assess referrals and accurately utilize software.

Verify and update patient demographic and insurance information.

Processing of orders/Data Entry

Creating new accounts as we received new patients

Working directly with Medicare as well as other major insurance companies to determine and verify the patients benefits/insurance and request any authorizations needed

research, analyze and interpret inquiries relating to claims processing issues

Assist Customer service with billing and collections for co-payments, deductibles, Co-Insurance

Receiving Grievances and Appeals from providers as well as members

Loading all supporting documentation and appeal letters as a PDF file into the system and creating individual files.

Sending out letters to Providers and members that filed appeals advising of receipt of the appeal/grievance and giving them the 15-day turnaround time, sending letters of extensions if necessary as well as sending a letter with the outcome of the appeal/grievance once completed.

Reviewing appeal/grievance and working the case by making an administrative decision or sending it to a consultant to review.

Closing all the cases before the maximum allowable time of 30 days

Education

2000 Excel High School Ft. Lauderdale, FL

General Studies-High School Diploma

Qualifications

Aggressive learner

Interpersonal, Reliable and organized

Excellent communication skills

Computer Skills

Microsoft Word/PowerPoint/Excel/ Outlook

10-Key Pad by Touch

Typing 55 WPM (Accurate)

CRM

Availity, Emdeon, EDS

Amisys

Portico

PEGA

Trucare

Omni

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