Data Entry Customer Care

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

***** ***** **. ********, ** **703

562-***-****!******************@*****.***

Profile:

Knowledgeable, articulate communicator with twenty-three years of customer care experience across the healthcare industry. Maintain strong decision-making and problem-solving abilities, as well as excellent time-management, data research, and data entry. Effectively train employees in network-based data entry systems and departmental procedures.

Skills:

• Wiring and Electricity

• Brazing

• Refrigeration Cycle

• Basic Electricity, Motors and HVAC Controls

• Air Conditioning Troubleshooting and Heat

Pump Systems

• Heating Systems and Boilers

• Duct Design, Blueprint Reading and Load

Calculations

• Specialized Commercial Equipment and

Green awareness

• Regulating and Building Automation

• Electrical and Mechanical Troubleshooting

Work Experience:

Appeals and Grievance Resolution Specialist 2015 to Present Cal Optima- Orange, CA

• Responds to verbal and written grievances and appeals from members and/or providers relating to member eligibility and benefits.

• Contract administration, claims processing, utilization management decisions, and pharmacy and vision decisions.

• Contact with members and families, health care providers, health networks, third party administrators and regulators.

• Collaborated with internal departments such as, Customer Service, Provider Operations, Pharmacy, Medical Management to identify factors necessary for the optimal resolution of grievances and appeals. “Maintains adequate information in Cal Optima’s systems; ensures data collection, summarization, integration, and reporting which includes case creation and management and events/activity tracking.

QIO Appeals Coordinator 2007-2015 United

HealthCare- Cypress, CA”

• Monitor the appropriateness, effectiveness, and quality of care provided to senior beneficiaries. Review Medicare appeals under CMS (Centers for Medicare and Medicaid Services).

• Review Hospital Inpatient, Skilled Nursing and Home Health appeals.

• Review medical records and letters with the state, to make a decision on the appeal cases.

• Work closely with Nurses. " Communicate with Medical Groups, out of country hospitals and CM Education

UEI College Garden Grove, CA 2021-2022

HVAC Diploma

Artesia High School, Artesia, Ca 1994-1998

High School Diploma

Certifications

EPA R410A

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