Customer service rep, insurance license

**/**** ********, **** *** Health Insurance License

CA Dept of Insurance

**/**** - **/**** ******** Service Representative III L.A. Care Health Plan, Los Angeles, CA

Provider Service Representative III L.A. Care Health Plan-Los AngelesCA Currently, I assist providers in heavy telephone queue regarding paid and unpaid claims, Processing of claims, payment issues, timely filing, Denials of CPT and Dx codes, Provide instructions on process for submitting corrected claims, appeal and eligibility status verification, Review and update Spreadsheets regarding contracted and non-contracted providers, including updating DOFR matrix. Review Provider disputes, and EOB request, authorization status, while updating IDT Salesforce, QNXT, NICE, Office Ally applications. Experience with pharmaceutical/medical insurance verification and authorization, Working knowledge of third-party payer verification terminology.

10/2023 - 01/2024 Participant Service Representative Motion Picture Industry Pension and Benefits, Studio City, CA Participant Service Representative Motion Picture Industry Pension and Benefits- Studio City, CA October 2023 to January 2024 Assisted Participants with Eligibility hours, claims and Pension questions. Familiar with QNXT and V3 programs. Guided Participants through web portal to answer questions on adding dependents, EOB downloading, submitting required paperwork, reviewing pension payments. 08/2022 - 10/2023 Medicare Sales Agent

Assurance IQ, Inc., Seattle, WA

Remote agent,

Taking incoming sales calls to assist potential clients with deciding what insurance plans they have and are available for them to increase their coverage. 05/2023 - 08/2023 CSR II Member and Provider Services Centene Corp, Sacramento, CA

This position handled high volume of inbound and outbound interactions involving member eligibility verification, general provider inquiries, claim status, general program and administration questions for State Medicaid line of business including direct member request for I.D cards and Primary Care Physician (PCP) changes, triage calls to appropriate units or outside entities. Verified claims status to inquire if claims are paid, pending or in appeal process.

Emigdio Valerio

12629 Ralston Ave., #5

Sylmar, CA 91342

Phone: 818-***-****

Email: ************@*****.***

Ability Summary

• Over 10+ years of customer service experience in the healthcare field

• Skilled in high volume incoming and outgoing calls, handling referrals, authorizations, claims review

• Excellent verbal and written communication skills; Bilingual in Spanish

• Knowledge of Medicare, Medicaid, Medi-Cal and Commercial Insurances

• Knowledge of Medical Terminology and HIPAA Guidelines

• Appeals & Grievance and heavy volume data entry

Occupational Licenses, Certificates and Training

Employment History

09/2014 - 04/2022 Medicare Customer Service Bilingual Blue Shield of California, Woodland Hills, CA

On queue, took various phone calls referring to Medicare Advantage and Pharmacy plans, claims, Dr. assignments, Dr. referrals., Worked with Part A, Part B and Part C plans, Supplemental and familiar with Medicare Appeals and Grievance protocol. Worked with IPA's and 3rd party providers.

General High School Curriculum

High School Diploma

San Fernando High School, CA

General Education

2 Years at College or a Technical or Vocational School CSUN, Northridge, CA

Education History

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