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Healthcare Customer Support & Insurance Specialist with 5+ Years in Medical Insurance and Customer Service
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Competencies
Efficiently managed claims and benefits verification, ensuring accuracy and compliance with industry standards.
Providing empathetic, effective assistance to resolve member issues and enhance customer satisfaction.
Guided clients through insurance enrollment processes, ensuring proper coverage and understanding.
Skilled in active listening, de-escalation, and persuasive communication to address member concerns.
Maintains awareness of HIPAA regulations, ensuring confidentiality and compliance in all interactions.
Education
Languages
Summary
Dedicated professional with over 5 years in medical insurance and customer service, adept at claims processing, member support, and insurance enrollment. Proven ability to resolve complex issues, enhance customer satisfaction, and ensure compliance.
Key Achievements
- Connected Medicare beneficiaries with licensed U.S. agents, facilitating optimal coverage solutions.
- Resolved complex customer issues, improving satisfaction and retention rates at IBEX NICARAGUA.
- Consistently exceeded KPIs such as AHT and CSAT in healthcare claims and customer support roles.
- Demonstrated strong communication and problem-solving skills to de-escalate frustrated members.
Experience
Medical insurance Soft sales
Connected prospective Medicare beneficiaries with licensed U.S. agents, clearly presenting plan benefits and guiding them toward the most suitable coverage options based on their needs.. Verified eligibility for Medicare Parts A and B and collaborated with major insurance carriers, including Humana and Blue Cross Blue Shield, to facilitate accurate and compliant enrollments.. Coordinated follow-up calls and scheduled appointments while managing client documentation via fax and email, ensuring a seamless and efficient application process.. Utilized strong persuasive communication and objection-handling skills to increase conversions and improve client retention, effectively addressing concerns and reinforcing the value of plan benefits.
Customer Service & Sales Representative
Assisted members through Member Services and Member’s Mark support, resolving issues related to shipments and product concerns (including appliances).. Coordinated with vendors to request replacements or solutions, ensuring timely resolution and customer satisfaction.. Assisted members with questions related to HMO and PPO plans, including eligibility, coverage limitations, referrals, prior authorizations, copays, deductibles, and out-of-pocket maximums.. Reviewed and explained EOBs (Explanation of Benefits) to patients, clarifying claim payments, adjustments, denials, and member financial responsibility.. Coordinated with providers, billing departments, and insurance carriers to obtain and submit required medical records and supporting documentation for claim reprocessing or appeals.. Educated members on in-network vs. out-of-network benefits and how to avoid unexpected medical bills.. Delivered high-quality customer service by de-escalating concerns, addressing sensitive health-related issues, and ensuring member satisfaction.. Handled high call volumes while meeting KPIs such as First Call Resolution (FCR), Average Handle Time (AHT), and Quality Assurance standards.
Healthcare Claims & Benefits Representative - CUSTOMER SUPPORT MEDICAL INSURANCE
De-escalated complex or frustrated-member situations using empathy, active listening, and problem-solving skills.. Met and exceeded key performance indicators (KPIs) such as AHT, CSAT, and conversion rates.. Documented all customer interactions accurately in CRM systems to ensure proper follow-up and compliance.