Remote Customer Service Representative

James G Jones

Cell: 951-***-****

Email: **********@*****.***

Qualifications:

• 11 years of Network and Healthcare Experience

• Excellent interpersonal, organizational, communication skills

• Customer Service, Medicare, Medical HMO Plans, HEDIS, Healthcare Informatics

• Critical thinking and sound judgment in crisis, Strategic thinker and problem solver

• Ability to manage multiple priorities with details and accuracy

• Ability to make decisions without deviating from company policies and procedures

• Held positions of increasing responsibilities production, project management and leadership

• Engaged others in providing solutions to problems without compromising quality assurance.

• Effectively coordinate and collaborate with all related departments and functions.

Professional Experience

March 2005-2020 DUC Learning Center Palm Desert, CA

Network Administer (On Call)

• Handle all Network Administration Protocols

• Provided computer network support to user workgroups

• Tested and evaluated hardware and software to determine efficiency, reliability, and compatibility

• Setup and Installed Network Servers and Workstation with Microsoft Windows update version

• Analyzed test data with recommendation requirements installation of hardware and software

January 2015 – May 2019 Advantmed Santa Ana CA (Seasonal Only)

Remote Customer Service Representative HEDIS Audits & HCC Review (Short-term contract)

• Handling Inbound/Outbound calls to Providers regarding HEDIS Audits and HCC review

• Follow up with Provider Staff to ensure information received according to HIPPA requirements

• Helped Provider’s with issues regarding HEDIS and NCQA verification

• Assist team members to ensure records processed in accordance with State Regulations.

• Updated database with dates and pre-qualification on HEDIS and HCC reviews

•Handle confidential information with discretion and professionalism HIPPA/PHI certified

June 2014 – January 2018 Quinn Community Outreach Corporation Moreno Valley CA

Navigator Consultant

• Qualified and enrolled individuals in Affordable Health Exchange, Qualified Health Plans (QHPs) through the Exchange

• Educated clients in HMO, Medicare and Medi-Cal benefits

• Handled inbound and outbound calls regarding health plan inquiries

• Managed and processed all requests through phone and email

• Face to Face communicate with potential Covered California enrollees utilizing Excel and PowerPoint

• Handle confidential information with discretion and professionalism HIPPA/PHI certified

• Utilized electronic tools and information needed to successfully enroll individuals in the health insurance exchange with Covered CA.

March 2010 – January 2015 Pacific Health Systems Pomona, CA

Customer Service Representative

• Researched complaints regarding medical claims and reported outcomes to appropriate management

• Checked in clients, scheduled appointments and handled a high volume of calls

• Created and updated client data information, processed reports and reviewed discrepancies

• Educated clients in HMO, Medicare and Medi-Cal benefits

• Handled inbound and outbound calls regarding health plan inquiries

• Managed and processed all requests through phone and email

• Coordinated with staff to ensure accuracy and provided support to customers

Education:

Kaplan University – Davenport, IA (Online)

Bachelor of Science In process

Coastline Community College, Fountain Valley, CA

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