Customer Service Quality Assurance

Billy Gonzalez

Santa Teresa, NM

Summary

Bilingual (English/Spanish) healthcare customer service professional with robust experience in Medicaid and Medicare support, medical claims resolution, call auditing, and quality assurance.

Proven success in managing high-volume member interactions while supporting pharmacy coordination, provider selection, and benefits navigation.

Skilled in conducting on-floor call evaluations, identifying service deviations, and escalating adverse events to management in compliance with clinical and regulatory protocols.

Adept in CRM documentation, cross-functional collaboration, and continuous improvement initiatives. Recognized for delivering compassionate service with strict adherence to HIPAA and quality standards in fast-paced call center environments.

Education

High School diploma

Fabens High School in Fabens, TX

Skills

Bilingual Communication (English/Spanish – Read/Write/Speak Fluent)

Healthcare Call Center & Member Support

Call Auditing & Quality Evaluation

Adverse Event Reporting & Escalation

Medicare/Medicaid Claims Resolution

CRM Documentation & Case Tracking

Pharmacy Coordination & Prior Authorizations

PCP Assignment & Appointment Scheduling

HIPAA Compliance & Regulatory Knowledge

High-Volume Inbound/Outbound Call Handling

Team Collaboration & QA Partnership

Patient Advocacy & Issue Resolution

EHR System Navigation

Service Recovery & Continuous Improvement

CENTENE May 2024 – Feb 2025

Customer Service Advocate (Bilingual)

Provided high-quality bilingual support (English/Spanish) to Medicaid members by addressing inquiries related to claims, pharmacy concerns, provider assignments, and covered benefits.

Assisted members in updating Primary Care Provider (PCP) selections, verifying eligibility, and navigating their plan’s covered services.

Participated in call monitoring and quality review sessions, offering constructive feedback to peers to enhance service delivery and compliance.

Collaborated with the Quality Assurance (QA) team and management to address service deviations, support adverse event reporting, and implement improvement initiatives.

Conducted floor evaluations to assess employee adherence to protocols and supported QA efforts to uphold service excellence.

Worked cross-functionally with internal teams, including pharmacy support, to resolve prescription refill requests, address formulary inquiries, and escalate prior authorization issues.

Scheduled medical appointments for members and assisted in resolving access barriers to ensure continuity of care.

Maintained accurate and thorough documentation of all member interactions and service resolutions in accordance with organizational and regulatory standards.

Managed a high-volume inbound call queue (20–45 calls daily) while consistently meeting or exceeding service level agreements and quality metrics.

Ensured strict compliance with HIPAA guidelines and Centene’s internal policies while providing compassionate, culturally competent member support.

TRANSPERFECT CONNECT, El Paso, TX Oct 2023-May 2024

Bilingual Interpreter-English/Spanish

Interpreted real-time conversations between English and Spanish speakers across a variety of sectors including medical, insurance, financial services (e.g., Zelle), banking, utilities, and government agencies.

Handled high call volume in a fast-paced environment while maintaining accuracy, professionalism, and empathy across all sessions.

Acted as a critical communication bridge between service providers and Spanish-speaking customers, enhancing access to essential services.

Interpreted in complex scenarios requiring in-depth understanding of terminology across healthcare, banking, and financial compliance.

Ensured strict confidentiality and adherence to HIPAA and data privacy regulations when handling sensitive medical and financial information.

Demonstrated adaptability by managing diverse call types, including emergency medical requests, customer account verification, and payment authorization support.

Everise Jul 2023-Oct 2023

Bilingual Customer Service Expert

Provided high-quality bilingual support (English/Spanish) to Medicare members, assisting with benefits enrollment, eligibility verification, and general coverage questions.

Handled 20–50 inbound calls daily in a fast-paced contact center, ensuring timely resolution of member concerns related to Medicare and prescription drug benefits.

Assisted members in scheduling doctor appointments, navigating provider networks, and addressing pharmacy-related issues, including transfers to the appropriate pharmacy department.

Accurately documented all member interactions in the internal system for tracking, compliance, and continuity of care.

Maintained a strong focus on patient experience, clarity of communication, and HIPAA compliance, contributing to high member satisfaction and call quality scores.

Solar Kings, LLC, El Paso TX Aug 2018-Jul 2023

Operations Lead

Plan, develop, implement and direct the organization’s operational and fiscal function and performance. While providing renewable energy sales and service to residential and commercial customers.

Act as a strategic partner by developing and implementing the company’s plans and programs

Analyze and make recommendations on the impact of long range growth initiatives, planning, and introduction of new strategies and regulatory actions.

Develop credibility and authority for the finance leadership team by providing accurate analysis of budgets, reports and financial trends and operational procedures in order to assist the BOD and senior executive team.

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