Adriane Gomes
Escondido,CA
Summary
Results-oriented candidate known for outstanding communication, customer service and conflict resolution abilities. Focused individual brings diverse management skills and extensive background in wide range of call center functions. Grasps and articulates sensitive and complex situations with diplomacy and ease. Excellent communicator and dependable team player with strong understanding of insurance industry. Adept at building relationships with clients, brokers and other stakeholders while delivering outstanding service. Highly organized and detail-oriented with strong ability to identify potential risks and develop solutions.
Overview
20
20
years of professional experience
Work History
ACCOUNT SERVICE MANAGER ASSOC.
UNITED HEALTH CARE
01.2023 - Current
- Counseled policy holders on insurance coverage tailored to their specific situational needs
- Customer Service- Assist and explain complex information to best help each client
- Sales- Increase their plan coverage while also explaining different options available to them, issued premiums and explained business processes
- Case Management- Learn needs of those who call in and help them come up with their plan
- Making complex insurance policies easy to understand such as indemnity, ppo, accident, life, and health insurance plans.
- Selling Upgraded Benefits, using skills to help members through extreme circumstances, explaining how additional benefit plans can off set cost increase of their plan to help them in extraneous circumstances.
- Managed 30+ incoming calls and emails per day from customer's.
CLAIMS BENEFITS SPECIALIST
AETNA
01.2022 - 01.2023
- Adjudicate 25+ claims daily for Medical, Dental, and Mental Health
- Experience with Medicaid and managed care
- Process both front and back end claims, also did re-work, calculated stop loss
- 2+ years of experience with appeals, grievances and member complaints
- Process claims dropped due to errors from Electronic Claim System
- Ability to apply medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies
- Referenced multiple plans policies pertaining to claims that needed to be adjudicated.
- Resolved complex claims issues for improved customer satisfaction and reduced claim backlog.
- Managed high-volume caseloads, consistently meeting deadlines and maintaining accuracy in claim review.
- Enhanced claim processing efficiency by implementing new software and streamlining procedures.
- Monitored changes in legislation that could potentially impact the way claims are processed or paid out by insurance companies.
HOMESCHOOL EDUCATOR
TEACHER
01.2014 - 01.2022
- Followed academic curriculum provided by establishment, Taught multiple subjects to more than one subject
- Followed detailed materials on curriculum provided and taught a variety of subjects, Dealt with new concepts and evolving concepts.
DISABILITY ANALYST, CASE MANAGER, HUMAN SERVICES SPECIALIST 3, PSR3
STATE OF OREGON
01.2007 - 01.2013
- Determined eligibility for multiple programs such as Medicaid, food stamps, tanf, domestic violence, and pilot programs using multiple sources to follow rules, polices, and regulations
- 1 year of reviewing medical documents to screen for eligibility of social security disability, required reviewed medical documents and following Social Security Guidelines in determining eligibility for Social Security Disability.
- Experiencing in applying new and evolving policies to new and unique situations
- Ability to multi-task while handling high call volume and several different computer systems at the same time
- Meet guidelines with little to no exceptions or errors
- 6 plus years of working with terminal and rumba’s
- 7 plus years working under high demand jobs, production focused, and demand for thorough and error free work.
- Ability to compose written correspondence free of grammatical errors while also translating medical and insurance expressions into simple terms that members can easily understand
PHARMACY SERVICES MANAGER
REGENCE BCBS
01.2004 - 10.2007
- Managed daily operations of the team, including assigning tasks, setting priorities, and resolving issues
- Developed and implemented strategies to improve customer service quality and call center performance
- Provided leadership, guidance, and support to staff, and foster a culture of collaboration, accountability, and excellence
- Conducted regular performance reviews, feedback sessions, and coaching forb staff, and address any performance or behavioral issues
- Analyzed and reported on workload, productivity, and quality metrics, and identify areas for improvement
- Coordinated and facilitated training and development programs for staff and ensured that they were updated on latest industry trends, best practices, and system changes
- Handled escalated and complex claims issues, and provided solutions and recommendations.
- Managed approximately 8-12 staff in which where trained, hired, monitored, and motivated under my supervision
Appeals & Grievances Coordinator
REGENCE BCBS
2002 - 2004
- Ensured compliance with regulatory requirements by maintaining accurate records and submitting timely reports.• Analyze/research/understand how a service/procedure/authorization was processed and why it was denied/modified
- Increased accuracy in case evaluations by conducting thorough research on relevant policies and guidelines.
- Served as a liaison between the organization and regulatory agencies, keeping all parties informed of case progress and outcomes.
- Managed high-profile cases with professionalism, ensuring that sensitive issues were handled discreetly while still achieving favorable outcomes for all involved parties.
- Processed and finalized appeals and grievances within agreed-upon turnaround time. Submitted verbal and written notification to members and providers.
- Reduced grievances and arbitration needs by educating frontline managers on techniques for enhancing interactions between labor and leadership.
- 2+ years of experience with appeals, grievances and member complaints
Ability to compose written correspondence free of grammatical errors while also translating medical and insurance expressions into simple terms that members can easily understand - Analyzed ,researched, understood how a service, procedure, authorization was processed and why it was denied or modified
Obtain relevant medical records to submit appeals or grievance for additional review, as needed
Leverage appropriate resources to obtain all information relevant to the claim modified or denied service
Education
Bachelors Of Science -
Portland State University
Portland, ORAssociates of Science -
Chemeketa Community College
Skills
- Leadership/Management experience
- Recruitment, training, performance review, resolving issues, and scheduling
- Ability to interpret, analyze and explain complex rule, regulations, and guidelines
- Typing skills over 40 WPM
- 5 plus years of experience in rhumba or terminal use and ability to use multi-systems to gather information
- Problem detection and Resolution
- 8 plus years in customer service/sales
- Complex Problem Solving
- Ability to interpret, analyze, and translate complex information in fast-paced environment in layman’s terms
- Ability to compose written correspondence free of grammatical errors while also translating medical and insurance expressions into simple terms that members can easily understand
- Over 10 plus years in sales experience
- Strong analytical skills
License
4289797, INSURANCE PRODUCER, ACCIDENT & HEALTH OR SICKNESS, LIFE
Professional Highlights
- 5+ years Insurance Sales and General Sales Experience combined
- 2+ Management experience in call center setting
- 2+ years Team Lead Experience
- 6+ years in claims processing
- 4+ years Leadership, training, and experience in descalation
- 2+ experience appeals, grievances, and member complaints
- Licensed Insurance Producer for Health, Life, and Accident Insurance
- 2+ years extensive case management experience
Timeline
ACCOUNT SERVICE MANAGER ASSOC.
UNITED HEALTH CARE
01.2023 - Current
CLAIMS BENEFITS SPECIALIST
AETNA
01.2022 - 01.2023
HOMESCHOOL EDUCATOR
TEACHER
01.2014 - 01.2022
DISABILITY ANALYST, CASE MANAGER, HUMAN SERVICES SPECIALIST 3, PSR3
STATE OF OREGON
01.2007 - 01.2013
PHARMACY SERVICES MANAGER
REGENCE BCBS
01.2004 - 10.2007
Bachelors Of Science -
Portland State University
Associates of Science -
Chemeketa Community College
Appeals & Grievances Coordinator
REGENCE BCBS
2002 - 2004