Customer Service Representative

Location:

Pasadena, TX, 77505

Posted:

November 28, 2024

Contact this candidate

Resume:

Crystal Sevilla

*******.*******@*****.*** 281-***-**** Webster, TX

SUMMARY

Seeking Medical Insurance Specialist role with 14 years of customer service and healthcare experience. Excelled in resolving provider inquiries, claims adjustments, and eligibility verification at Community Health Choice; adept in Medicaid, Medicare, Health Insurance Market Place plans and bilingual communication. Recognized for exceptional service and team support, with a strong understanding of healthcare benefit plans and regulations. WORK EXPERIENCE

Community Health Choice Houston, TX

Provider Service Representative III Dec 2014 - Jan 2024

• Resolved provider inquiries related to claim payments, denials, and appeals, submitting adjustment requests when necessary.

• Scheduled specialist appointments, enhancing member access to healthcare services.

• Processed provider verification requests for eligibility and benefit coordination, maintaining accurate documentation and follow-up.

• Provided clear, comprehensive information to providers and members on health benefit plans via telephonic and written communications.

• Recognized for outstanding customer service through positive quality monitoring assessments and Provider Satisfaction Surveys.

• Supported team effectiveness by assisting with eligibility verification, member education, and training new hires.

• Identified and addressed claims denial trends, initiating mass adjudication processes to prevent future errors and reduce call volume.

• Maintained current knowledge of Texas Medicaid Provider Procedure Manual for precise benefits and eligibility verification.

• Managed authorization inquiries, guiding providers on how to request authorizations and ensuring accurate information on required CPT codes.

• Developed and tested IVR system, created training materials, and ensured compliance with eligibility and member service requests.

City of Houston Water Department Houston, TX

Customer Service Representative II Feb 2011 - Dec 2013

• Addressed bilingual inquiries and processed payments for utility services, enhancing customer relations.

• Established and negotiated payment arrangements, contributing to better financial outcomes.

• Managed account adjustments and coordinated field service activities, ensuring issue resolution.

• Delivered customer service for high-level inquiries in both Spanish and English through various channels.

• Facilitated payment agreements for customers facing financial challenges, improving retention.

• Conducted collection calls and structured payment plans for diverse accounts.

• Performed precise data entry to maintain accurate customer records.

• Dispatched field work orders and managed service requests efficiently.

• Communicated updates on municipal ordinances and rate changes to customers.

• Processed account transactions, including balance transfers and adjustments. MASH INC Houston, TX

Patient Advocate Oct 2010 - Jan 2012

• Assessed client eligibility for Medicaid, Medicare, and Social Security by accurately completing and submitting necessary applications in compliance with state guidelines.

• Facilitated victim of crime applications, ensuring client representation and submission to appropriate channels

• Identified and provided clients with pertinent resources specific to their geographical location, utilizing active listening and empathetic communication to understand their needs.

• Maintained strict adherence to HIPAA standards during all client interactions, including the secure handling of sensitive information.

• Managed a high volume of inbound calls, efficiently addressing client inquiries and concerns.

• Conducted outbound calls to clients, ensuring timely follow-up and resolution of issues.

• Supported team objectives by contributing to project work and meeting established deadlines, maintaining high-quality standards in all tasks.

Midas Tire & Auto Houston, TX

Customer Service Representative Feb 2010 - Dec 2011

• Greeted and processed check-ins for an average of 20-30 clients daily, ensuring a warm and efficient welcome.

• Coordinated appointment scheduling and confirmations utilizing phone and email, while seamlessly integrating walk-in requests.

• Resolved client inquiries and provided detailed assistance across multiple communication platforms, including in-person, phone, and email interactions.

• Facilitated distribution of necessary forms to clients, ensuring accuracy and completeness of information prior to services.

• Allocated tasks among technical staff and communicated service estimates to clients for transparency and approval.

• Managed the collection and processing of client payments, maintaining accuracy in financial transactions.

• Maintained comprehensive digital and physical client records, ensuring data integrity within the Point-of-Sale

(POS) system.

MJ Amusements Pasadena, TX

Inventory Specialist May 2011 - Aug 2011

• Maintained optimal inventory levels to support product availability and operational efficiency.

• Handled shipping and receiving duties, facilitating smooth logistical operations.

• Conducted payment processing and upheld precise record-keeping for financial reporting.

• Managed the specialized inventory database for HASP 4 and SRM keys, ensuring accuracy and security.

• Developed and oversaw a detailed spreadsheet tracking store inventory transactions.

• Participated in the procurement process, including the ordering of necessary parts and equipment. Midas Houston, TX

Customer Service Representative Feb 2010 - May 2011

• Greeted and processed check-ins for an average of 20-30 clients daily, ensuring a warm and efficient welcome.

• Coordinated appointment scheduling and confirmations utilizing phone and email, while seamlessly integrating walk-in requests.

• Resolved client inquiries and provided detailed assistance across multiple communication platforms, including in-person, phone, and email interactions.

• Facilitated distribution of necessary forms to clients, ensuring accuracy and completeness of information prior to services.

• Allocated tasks among technical staff and communicated service estimates to clients for transparency and approval.

• Managed the collection and processing of client payments, maintaining accuracy in financial transactions.

• Maintained comprehensive digital and physical client records, ensuring data integrity within the Point-of-Sale

(POS) system.

Speedy Cash Houston, TX

Customer Advocate Jan 2009 - Jan 2010

• Managed daily financial tasks, including bank validations and credit evaluations, and efficiently processed MoneyGram and Western Union transactions.

• Monitored and identified fraudulent activity during check cashing; reported suspicious cases to relevant authorities.

• Assisted clients with the application process for various financial services, ensuring accuracy and compliance.

• Delivered high-quality customer service by resolving disputes swiftly and administering financial products such as payday advances and title loans effectively.

EDUCATION

Pasadena High School

Diploma

Pasadena, TX

May 2007

San Jacinto College

Associate's Degree, Business

Pasadena, TX

LANGUAGES

Spanish, Read/Write/Speak

SKILLS

Salesforce • Provider Credentialing • Remote work • Bilingual Spanish • QXNT • Conflict resolution • Analytical skills • Insurance Policy Interpretation • OCIS • Knowledge of Healthcare Regulations • JIVA • JAVA ADDITIONAL ACTIVITIES

Casa De Amigos Health Fair, Community Health Choice Apr 2015 - Apr 2017