• Reviewed Customer Service Representatives (CSRs) electronic, telephone, and written inquiries to coach and develop CSR processes and KPIs. Investigated, analyzed, researched, and responded to electronic, telephone, and written referral inquiries from groups, plan partners, and/or other external contacts as needed.• Subject Matter Expert (SME) selected to resolve escalated complaints and complex inquiries to strive for world-class customer service.• Analyzed and researched root cause… Show more • Reviewed Customer Service Representatives (CSRs) electronic, telephone, and written inquiries to coach and develop CSR processes and KPIs. Investigated, analyzed, researched, and responded to electronic, telephone, and written referral inquiries from groups, plan partners, and/or other external contacts as needed.• Subject Matter Expert (SME) selected to resolve escalated complaints and complex inquiries to strive for world-class customer service.• Analyzed and researched root cause of identified issues and developed optimal solutions.• Collaborated with internal departments (Provider Relations, Billing, Sales/Marketing, Claims) to research and develop resolution of issues.• Partnered with the Customer Operations team to monitor and report on all KPIs, CSR status and schedules for efficient tracking.• Alerted leadership of identified deficiencies.• Created, updated, and facilitated content on current processes, product knowledge, and best practices.• Built and supported engagement plans for Customer Operations teams.• Autonomously instructed onboard training with new employees, offering additional support during live provider and member calls to achieve success and meet employer metric goals. Show less

• Recorded all quality of care and quality of service complaints and potential quality referrals initiated by members and internal and/or external clinicians. • Reviewed clinical and dental records for completeness and determines administrative or clinical complaint. • Performed research and identified key policy provisions such as clinical guidelines, plan policies, EOC, regulatory guidelines, and DMHC/DHCS rules and regulations. • Summarizes cases including articulation of… Show more • Recorded all quality of care and quality of service complaints and potential quality referrals initiated by members and internal and/or external clinicians. • Reviewed clinical and dental records for completeness and determines administrative or clinical complaint. • Performed research and identified key policy provisions such as clinical guidelines, plan policies, EOC, regulatory guidelines, and DMHC/DHCS rules and regulations. • Summarizes cases including articulation of complainant’s perception and present essential information to Dental Consultant for review.• Assigns reviews to clinical staff for those requiring clinical reviews. • Worked with the Clinical Quality Consultants, Dental Consultants, and other clinical staff to ensure that clinical issues are appropriately evaluated. • Prepared case files external (including IRE) review of complaints as appropriate.• Identified the root causes of complaints and worked with the applicable operational departments to implement an appropriate resolution.• Communicated these resolutions to the complainant via telephone or written correspondence.• Assisted with additional duties as assigned. Show less

· I provide expert support and respond to inquiries regarding ADP products via phone and email. · I use strong interpersonal skills and product knowledge to communicate with customers, resolve issues, and assist in the use of ADP products and systems.· I follow up and follow through on new projects, requests, and cases. · I ask relevant questions to define the root cause of a problem, generate solutions, decide on a course of action, and be accountable for the actions and decisions… Show more · I provide expert support and respond to inquiries regarding ADP products via phone and email. · I use strong interpersonal skills and product knowledge to communicate with customers, resolve issues, and assist in the use of ADP products and systems.· I follow up and follow through on new projects, requests, and cases. · I ask relevant questions to define the root cause of a problem, generate solutions, decide on a course of action, and be accountable for the actions and decisions made. Show less

· Perform quality assurance reviews on pre/post adjudicated claims.· Review, analyze, and compile financial and procedural data.· Manually calculate processed claims to verify system.· Review claims for procedural and financial accuracy and determine the financial impact of errors identified.· Identify, quantify, and examine trends pertaining to claims accuracy and compliance to group contracts and Delta’s policy and procedures. · Investigate processing issues or problems… Show more · Perform quality assurance reviews on pre/post adjudicated claims.· Review, analyze, and compile financial and procedural data.· Manually calculate processed claims to verify system.· Review claims for procedural and financial accuracy and determine the financial impact of errors identified.· Identify, quantify, and examine trends pertaining to claims accuracy and compliance to group contracts and Delta’s policy and procedures. · Investigate processing issues or problems and recommend solutions. · Conduct and participate in problem resolving meetings with divisional management. · Responsible for handling appeal requests from the claims area. · Acts as a liaison and resource with line supervisors and training staff to identify training needs and improve the quality of work performed· Support the orientation and cross training of new subordinates, familiarizing them with policies/procedures and job responsibilities within the area to enhance team performance.· Communicate and collaborate with Quality Assurance team members to address and manage daily and weekly workload goals and resolve issues encountered. Show less

· Responded to complex telephone, electronic, written inquiries from dental or vision professionals, groups, subscribers, and brokers.· Expediently accessed reference materials to analyze and determine appropriate responses to telephone, electronic and written inquires.· Communicated eligibility, benefits, and claims status, policies, and procedures.· Documented each customer encounter and resolution in the appropriate computer tracking system and adjusts claims as necessary based… Show more · Responded to complex telephone, electronic, written inquiries from dental or vision professionals, groups, subscribers, and brokers.· Expediently accessed reference materials to analyze and determine appropriate responses to telephone, electronic and written inquires.· Communicated eligibility, benefits, and claims status, policies, and procedures.· Documented each customer encounter and resolution in the appropriate computer tracking system and adjusts claims as necessary based upon findings. · Identified, report and document system discrepancies. · Accurately completed online, hard copy forms and route to the appropriate department. · Met and maintain production standards, counts and inquiry response turnaround times and reprocesses claims, appropriate. · Used contact tracking functions to follow-up on open calls to ensure issues are resolved within standards. Show less

· Responded to basic telephone, electronic, written inquiries from dental or vision professionals, groups, subscribers and brokers or customers.· Expediently accessed reference materials to analyze and determine appropriate responses to telephone, electronic and written inquiries.· Communicated basic eligibility, benefits and claims status and forward specific inquiries as directed for priority resolution.· Accurately completed online, hard copy forms and route to the appropriate… Show more · Responded to basic telephone, electronic, written inquiries from dental or vision professionals, groups, subscribers and brokers or customers.· Expediently accessed reference materials to analyze and determine appropriate responses to telephone, electronic and written inquiries.· Communicated basic eligibility, benefits and claims status and forward specific inquiries as directed for priority resolution.· Accurately completed online, hard copy forms and route to the appropriate department.· Documented each customer encounter or resolution in the appropriate computer tracking system.· Obtained pertinent patient demographics and document this information in a patient database when required. · Provided information for subscribers such as questions pertaining to insurance, billing, claims or eligibility.· Identified, report and document system discrepancies. · Met and maintain production standards, counts and inquiry response turnaround. Show less

· Resolved customer inquiries pertaining to claims, benefits and other inquiries. Responded to requests in an effective and timely manner.· Prepared adjustments for services not properly processed, either systematically, or by forwarding to the appropriate area for follow up and resolution.· Met all production, quality, and adherence standards. Attended all required training classes.· Maintained accurate records, including timekeeping records.

· Provided quotes for customers who are looking for motorcycle insurance· Sold insurance policies · Properly underwrite the right coverages based on risk assessment· Input customer information into database· Gave features and benefits of insuring with Geico· Provided excellent customer service in a call center environment· Formed and managed a board of directors to assist in planning and executing future success.