Service Representative Customer

PROFESSIONAL SUMMARY

An innovative, diligent, results-driven manager with 10+ experience with a proven track record of success in leading initiatives and streamlining business strategies to ensure efficiency and profitability. Consistently recognized by leadership for superior performance, master trouble-shooter and creative problem-solving abilities. Adept in providing exemplary customer service, coaching and mentoring employees and achieving your organization’s goals and objectives.

EXPERIENCE

US Family Health Plan New York, New York

Member Service Manager 2020– present

Member Service Supervisor 2016 - 2020

Member Service Team Lead 2009- 2015

●Introduced improvements to the on-boarding process for the new claims adjudication system (Conduent).

●Increased and have maintained a sustained customer satisfaction rate which ranked USFHP top two preferred choices for DoD contractors over 10+ years.

●Designed manuals for initial new hire on-boarding on Tricare, Medicare and Department of Defense (DoD) federal rules, regulations, policies, IVR, CRM, & 1500 / UB-04 claims.. Also, spearheaded continuous biweekly refresher training for new, existing employees and cross-functional teams while ensuring regulatory and accreditation compliance.

●Facilitated several initiatives to increase employee retention resulting in decreased turnover by 30%: invested in team-building events & implemented professional development for my Team which resulted in increased employee satisfaction. This also catapulted them into several other positions within the organization including promotions into managerial roles.

●Achieved and maintained the company's 5% abandonment goals as call volume increased by 19% (12K phone calls) in the center since Q2 of 2016. Led the Team through the transition of the Utilization Review (UR ) vendors and worked closely with Leadership and cross-functional teams to design revised workflows for optimal efficiency.

●Liaised between members/providers and cross-functional Teams to communicate trending Key Performer Indicators ( KPI) in order to proactively minimize dissatisfaction

●Compiled annual & probationary performance appraisals.

●Monitored member and provider complaints and initiated root cause analysis. Prepares monthly reports for the Operations Director to show resolution to each complaint and discuss action plans to reduce the likelihood of recurrence.

●Access Medicare (CMS) and Tricare reimbursement methodologies to analyze medical claim payment for appeals, post-payment audits, overpayment and grievances.

Healthplex New York, New York

Customer Service Representative 2005 - 2009

●Provided resolutions for members concerning their dental coverage, status of claims, and provider data while upholding the highest level of customer service.

●Responded accurately to daily customers’ inquiries in a high volume inbound call center via telephone, and emails regarding benefits, regulatory items and policy and procedures.

●Met and exceeded standards of quality and professionalism; as well as, courteous service to all lines of business.

EDUCATION

Long Island University Brooklyn, New York

Sociology, Bachelor of Arts June 2009

SKILL HIGHLIGHTS

Microsoft Office Suite, Google Workspace, CRM Salesforce, Project Management, Quality & Safety Compliance, HR and Training Support, Cross-Functional Team Collaboration, Reports Preparation and Filing, Strong Leadership Skills, Strong Work Ethic, Excellent Internal & External Communication Skills, Risk Management & Assessment, DoD Confidential Clearance, Analytical Thinking, HIPAA Regulatory Certified

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