Customer Service Specialist
Resume:
GAIL FLORES
*************@*****.***
CUSTOMER SERVICE LEADER
Highly effective Customer Service Professional with more than 20 years of customer service excellence, within the diverse industry of healthcare. Experienced in provider relations with a proven record of excellence. Expertise in positive issue resolutions with partnering providers, with stellar customer satisfaction.
EXPERTISE IN
Business relations Case management Presentation development
Process improvement Public Speaking Marketing /Expense Reporting
Community Outreach Research/Development Onboarding
PROFESSIONAL EXPERIENCE
June 2014 – July 2021 DaVita Inc.
Home Modalities Team • Clinical Kidney Educator/ Coordinator
Key Responsibilities:
Community Outreach * Marketing Providers * Physician Education Management * Data Reporting * Process improvement development * Fostered Provider/ Business Relationships * Training*
Marketed, Piloted, and Improved the Rollout Process of internationally known kidney education program called Kidney Smart. The program provides education to patients/families dealing with kidney disease: diet, treatment options, insurance advise, for one of the largest kidney care companies in the United State
Managed and provided all patient education/comprehensive medical insurance advise for 13 facilities, as well as eight nephrology groups. Case Management of approximately 270 Acute patients a year. With an emphasis on adult/senior populations. With continued follow up on time-based schedule. According to diseased stage, and in collaboration with assigned Physician’s direction. Tasked with training New Hires, Practice Office Managers, and staff on the importance of upstream Education prior to a patients start date. Data reporting on a biweekly basis. Fostered Nephrology partner relationships, with stellar outcomes. Time management and organization of all scheduled kidney education classes in north and south Orange County.
November 2006 – June 2014 DaVita Inc.
Insurance Management Team• Benefits Insurance Advisor
Responsibilities:
Patient Advocate/Liaison between, employers, commercial insurance payers, and all Government payers. Liaison between facility teammates, billing office and the corporate office to resolve patient insurance payment issues and/or patient care concerns. Identify, resolve, or escalate issues as appropriate chain of command for prompt and effective resolution. Proactively help build relationships with patients, Facility Administrators, clinical/ regional resources to emphasize and integrate Insurance Management priorities* Preform Patient Financial Evaluations to determine if payment or payment arrangements are an option in-coordination with helping patient find 100% coverage insurance. Responsible for managing thirty-seven facilities in payment resolution. Experienced with ERISA, ACA, COBRA, FMLA, ADA. Review and keep accurate records of Patient by Payor reports/uninsured. Handled Grievance, Appeals, and Coordinated open enrollments for all patients in my lane. Hot Spot special enrollment SME. Cash Payment SME, Cobra SME.
March 2002– November 2006 DaVita Inc.
Regional Reimbursement Specialist• Revenue Management.
Grievance, Appeals, and resolution: of under payments, denials, rejected claims. Extensive knowledge of (PPO, POS, HMO, EPO, Medicare, Medicaid) payers. Maintained open communication with payors, contracting and Patients. Regarding disputed claims and reimbursement discrepancies. Identified trends, preformed root cause analysis on unpaid / under paid claims in a timely manner to secure payment receipt. Reviewed 30/60/90 payor reports. Collaborated with facilities administrators on non-contracted payors, and cash payors including our international partners. Functioned as a liaison in negotiating a fair market reimbursement return on care. Authorizations SME
Team leader, relationship management, communication, multi-tasking skills, time management skills.
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