Customer Service Support
Resume:
Monique Macias
Silver Springs, NV *****
*******.**********@*****.***
Professional Summary
Ability to provide world class customer service in a changing, fast-paced operation work environment where I will be able to utilize all my skills expertise as Medical Claims Specialist, Data Entry and Customer Support, I’ll be able to use my vast background in all areas and to be able to excel with any given tasks. With my experience using tact and diplomacy while working with clients in high pressure situations, I can become an asset to any company.
Willing to relocate to
Authorized to work in the US for any employer
Willing to relocate: Anywhere
Authorized to work in the US for any employer
Work Experience
Medical Claims Coverage Determination and Appeals
CVS-Remote
September 2024 to April 2025
• Comfortable managing a case load in a system of record meant for managing appeals from start to finish,
• Responsive to emails and demonstrate proper email etiquette in general
• Reliable and detail-oriented, engaged in the work and learning the work
• Enthusiastic about learning how to use the reference materials developed to ensure consistency and compliance,
• Enjoy reaching out to team mates for questions and support in a 100% virtual setting.
- Applied medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment. measures to assist in the claim adjudication process.
- Handled phone and written inquiries related to requests for pre-approval/pre-authorization, reconsiderations, or appeals.
- Insured all compliance requirements are satisfied and all payments are made against company practices and procedures.
- Identified and reports possible claim overpayments, underpayments and any other irregularities.
- Performed claim rework calculations.
- Assisted with claim benefit specialists.- Made outbound calls to obtain required information for claim or reconsideration.
Medical Claims Representative -Remote
Fortuna BMC / Gainwell Technologies LLC-Sacramento, CA February 2023 to June 2024
Responsible for assisting moderately complex provider telephone calls, handling requests for claim research inquiries, responding to written provider inquiries and conducting stellar customer service.
• Experienced with Microsoft Excel and Microsoft Outlook.
• Prior Authorization verification with both Providers and Members.
• Research provider calls/inquiries and responds to appropriate parties in accordance with service level agreements (SLAs).
• Documents calls in a customer relationship management (CRM) ticketing solution, resolves written provider requests/inquiries and updates provider history with results of inquiry to include proper documentation.
• Interfaces with team personnel, management, and customers in reference to customer service issues.
• Conducts outbound calls to providers in response to voicemail inquiries, customer direction or other business needs
Unemployed due to COVID-19
Sacramento, CA
November 2022 to February 2023
Sadly, I was out of work due to having COVID for a few months. Customer Support Specialist (Remote)
Health Net, Inc. / Centene-Sacramento, CA
July 2021 to November 2022
• Answer calls and respond to emails from members, and providers. Provide eligibility, authorizations, enrollment, and provide payments/billing, and claim status, and ID cards.
• Prove strong problem-solving skills by assessing a problem, researching a solution, and working with a customer to completion
• Proficient with Microsoft Excel and Microsoft Outlook.
• Expedite correction or adjustment; follow up to ensure resolution.
• Serves as the advocate for providers by demonstrating accountability and ownership to resolve issues
• Quickly and appropriately triage contacts from healthcare professionals (i.e., physician offices, clinics, billing offices)
• I listened to understand and identify the needs of the provider, answering questions and resolving issues (e.g. benefits and eligibility, billing and payments, clinical authorizations, explanation of benefits, behavioral health)
• Researched and dissected complex prior authorization and claim issues and took appropriate steps to resolve and identified issues to avoid repeat calls, escalations, and provider dissatisfaction
• Collaborated effectively with multiple internal partners to ensure issues are resolved and thoroughly
• Strong multitasking I was able to effectively and efficiently navigate more than 30 systems CSR - Customer Service Representative
YDesign Group-Sacramento, CA
November 2017 to December 2020
Respond to multiple inbound calls and chats at a time both quickly and professionally while I accelerated at multitasking, I had to maintain excellent reading comprehension, use of grammar, spelling, and punctuation.
• Proactively and strategically engage with customers while identify customer needs and providing solutions
• Qualify leads and register TPS for Lumens trade Advantage Program
• Establish rapport with TPS at a transactional level
• Create, update, and maintain customer records by logging notes and activity within our CRM
• Maximize opportunity to drive revenue
• Provide excellent customer service standards through quality interaction and ownership Key Performance Metrics:
• Team chat net bookings
• Chat count and quality
• Customer satisfaction scores
Customer Coordinator
Jacmar Foodservice Distribution-Sacramento, CA
August 2017 to September 2019
I personally established and maintained a high level of customer satisfaction. Professionally communicated with the other departments as necessary to resolve unique customer concerns. Input orders and other required information via fax, phone and computer.
• Extract information from company IT system as needed to service the customer (example: inventory levels, pricing, product information, and credit)
• Understand and manage customer purchase patterns and anticipate variances
• Communicate and work with our Customer Service Specialists to review daily order activity and working to find solutions when necessary
• Responsible for developing a business plan for the territory build and continuously re-evaluate territory goals and account for achieving sales and gross profit goals for the district
• Participate in marketing functions, sales meetings, and other merchandising programs
• Available occasional weekends as needed
• Provided assistance to clients
• Answered phone and assisted clients with changes
• Assisted customers in person
• Created customer appointments
• Scheduled reservations for customers
• Maintained up-to-date knowledge of customer accounts
• Inventoried stock
• Confirmed payments, refunds, etc.
• Resolved payment and order disputes
Administrative Assistant
XPO Logistics-Stockton, CA
August 2017 to March 2019
• Updating and maintaining excel logs for administration duties
• Composes routine letters/emails and replies based on general instructions.
• Coordinates and dispatches multiple drivers.
• Juggles phone calls, team communication, and computer duties.
• Asserts time management to maximize efficiency and profits.
• Create a professional and positive team environment by modeling appropriate behaviors.
• Locate Overages, Shortages and Damaged freight
• Handle many different types of freight; including Hazmat Materials
• Responsible for maintaining a clean and organized OS&D area
• Responsible for preparing all paperwork and the repackaging of all OS&D freight
• Research and Resolve OS&D freight issues
• Maintain accurate records for reporting all OS&D Freight on a Daily/Weekly basis to service center management
• Assist with answering telephones, provide quality customer service and assist with resolving customer concerns efficiently
Education
High school diploma in Basic Studies
William Daylor
September 2002 to June 2004
Skills
• Phone Etiquette (10+ years)
• D.O.T Compliance (3 years)
• Troubleshooting
• Customer Relationship Management
• Call Center
• English
• Customer Service
• Windows (10+ years)
• Customer Care
• Remote Access Software
• Customer Support
• Cold Calling
• Microsoft Outlook
• Account Management
• Active Directory
• Desktop Support
• Fraud (4 years)
• Freight Experience
• Live Chat
• Network Support
• Computer skills (10+ years)
• Cash management
• Computer Networking
• CRM Software
• Upselling
• VPN
• Multi-line Phone Systems
• Negotiation
• Microsoft Powerpoint
• Data Entry
• CSR
• Microsoft Excel (10+ years)
• Help desk (4 years) Email Etiquette Microsoft Excel Professionalism Graphic Applications Microsoft PowerPoint Telephone Procedure's Windows / Chrome Internet
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