Customer Service Chula Vista

Mary Rubalcava

**** ******** ***. ***** *****, CA 91911

Phone: 619-***-**** Email: *************@*****.***

Education

Bachelor of Science – University of Phoenix, San Diego, CA (2007)

Communico - The Magic of Customer Relations Program – Chula Vista, CA (2017)

San Diego Job Corp – Business Tech Trainee – Imperial Beach, CA (2017)

Professional Summary

Dedicated and self-motivated Senior Audit Analyst with a strong background in customer service and audit controls. Proven track record of successfully consulting on multifaceted projects, developing and implementing effective audit strategies, and collaborating with team members and business partners to enhance system efficiency and integrity. Recognized for outstanding performance and resolving complex audit control issues. Known for strong organization, efficiency, priority management, and communication skills. Proficient with modern audit systems and software applications.

Areas of Expertise

Customer Service & Audit Controls

HIPAA & Regulatory Compliance

Audit Strategy Development

Grievances & Appeals Management

Claims & Authorization Management

Data Analysis & Reporting

Internal Audit & Quality Improvement

Software: Health Edge, Jira, EviCore, Novologix, AWS, Health Rules Manager, RTTracking, Midtrack, HSP, Davis Vision CSP

Professional Experience

Innovare Corporations (Clover Project) – San Diego, CA

Sr. Grievance and Appeals Analyst (Remote) 07/2023 – 08/2024

Managed provider dispute intake process using Health Edge.

Utilized Jira for communication with the claims department via internal ticketing system.

Worked with EviCore and V-Pay to view authorization status and resolve intake processes.

Leveraged Novologix and Health Rules Manager to track and resolve claims and cases.

Managed acknowledgment and resolution letters for grievances and appeals.

Collaborated with claims, authorization, RN/MD departments to ensure case accuracy and resolution.

Experienced with AWS applications for claims management.

Innovare Corporations (Versant Project) – San Diego, CA

Sr. Grievances and Appeals Analyst (Remote) 06/2023 – 03/2024

Audited complaints, appeals, and grievances, both delegated and non-delegated.

Reviewed and audited cases using phone and medical records.

Applied knowledge of Health and HIPAA regulations to ensure compliance.

Utilized RTTracking system to resolve claims and authorizations.

Worked with CSP (Customer Service Portal) to check eligibility, claims, and call records.

Managed claims and authorizations using Midtrack 10.08.2 and HSP 1.8.

Administered eligibility and claims status checks through Davis Vision Customer Service Portal (CSP).

Community Health Group – Chula Vista, CA

Sr. Customer Service Quality Analyst 04/2017 – 01/2023

In-depth understanding of HIPAA, DHCS, and CMS regulations.

Led initiatives to improve auditing and quality improvement processes.

Conducted audits for grievances and determinations, ensuring regulatory compliance.

Audited member and welcome calls for documentation accuracy.

Monitored and audited daily TTY calls and data reports.

Maintained logs for all auditing processes.

Community Health Group – Chula Vista, CA

Member Service Specialist 04/2014 – 01/2017

Resolved member concerns and facilitated emergency transfers.

Documented all member and provider communications.

Assisted with Primary Care Site Charges and provided member assistance.

Managed audit controls for customer service quality and compliance.

Key Skills & Competencies

Audit Procedures & Controls

Customer Service & Member Support

Regulatory Compliance (HIPAA, DHCS, CMS)

Analytical & Critical Thinking

Attention to Detail & Organization

Proficient in Excel, Word, PPT

Fraud Prevention & Business Acumen

Internal Audit Experience in Medical/Medicaid

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