A-Lexus Ortiz
Cedar Hill,TX
Summary
Results-driven Qualified Agent with a proven track record of surpassing sales targets. Demonstrated expertise in building and maintaining customer relationships. Skilled in expanding market share and implementing successful initiatives.
Overview
6
6
years of professional experience
Work History
Fraud Detection Agent
PSCU Financial Services
03.2024 - Current
- Reviewed electronic credit and debit card cases generated by Falcon Fraud Detection System
- Detect known fraudster callers and potential new fraud patterns using knowledge and experience
- Handled lost/stolen account calls ensuring precise processing for liability mitigation
- Constantly track evolving fraud methods and analyze transaction patterns to identify trends
- Verify appropriate account activity, take correct actions, and place associated notes on accounts to minimize potential fraud loss, customer inconvenience, and loss of credit union revenue.
- Assisted customers with placing orders, answering questions about products, pricing, availability, product uses and credit terms.
- Developed customer relationships and ensured satisfaction with services.
Provider claims Representative
03.2023 - 02.2024
- Functions as the key intermediary for communications with Molina Health plan and Provider network serving its members
- External-facing, field-based role demands extensive job knowledge and organizational skills.
- Documented changes in claim statuses using specialized software systems.
- Collaborated with other departments to resolve billing disputes or address customer concerns quickly.
- Developed strategies to reduce the number of denied or delayed claims within assigned portfolio.
- Analyzed trends in claim denials or delays to identify areas for improvement within the organization.
- Educated customers on their rights under state and federal regulations governing insurance policies.
- Filed appeals on behalf of customers when necessary after denial of a claim due to insufficient evidence.
Senior Intake representative
01.2022 - 11.2022
- Collaborated with sites, patients, and physician offices to resolve pre-certification queries and issues efficiently
- Assisted with scheduling appointments for patients and family members.
- Provided information to patients regarding their insurance coverage, benefits, and payment options.
- Collected payments from patients or third-party payers according to established policies.
- Greeted customers and provided excellent customer service.
- Answered incoming calls in a professional manner, responding to inquiries or transferring them as appropriate.
- Maintained confidentiality of all patient information at all times.
Chat Specialist
08.2020 - 01.2022
- Handled customer inquiries via online chat
- Utilized diverse skills to resolve issues efficiently
- Researched customer complaints and billed accordingly.
- Responded to customer complaints and escalated complex cases to management as needed.
- Maintained detailed records of customer interactions, updating account information as necessary.
- Identified opportunities for process improvement, offering suggestions for streamlining operations.
- Monitored team performance metrics such as average response time and customer satisfaction scores.
- Created scripts for frequently asked questions to improve the efficiency of responses.
Customer Solutions Agent
Lewisville, TX
08.2018 - 07.2020
- Handled calls, responded to inquiries, resolved problems, and corrected policy mistakes
- Provided customer service to clients by responding to inquiries and requests via phone, email, and chat.
- Resolved customer issues quickly and efficiently while maintaining a professional demeanor.
- Conducted research to identify solutions for customer problems.
- Assisted with onboarding of new customers by providing guidance on product features and services.
- Identified customer needs and provided appropriate solutions in a timely manner.
Education
Duncanville High School
Duncanville, TX05.2008
Skills
- Schedule Management
- Critical Thinking
- Call Management
- Service support
- Contract Negotiation
- Flexible Schedule
- Positive Attitude
- Conflict Resolution
- Customer service abilities
- Customer Complaint Resolution
- Follow-up calling
- Customer needs determination
- Relationship Building
- Business Correspondence
- Policy understanding
- Coverage Determination
- Policy Knowledge
- Documentation Review
- Allocating claims
- Microsoft Office
- Claims trend analysis
- Investigation techniques
- Fraud prevention
- Confidentiality
- Transaction monitoring
- Transaction review
- Fraud patterns
- Risk level determination
Timeline
Fraud Detection Agent
PSCU Financial Services
03.2024 - Current
Provider claims Representative
03.2023 - 02.2024
Senior Intake representative
01.2022 - 11.2022
Chat Specialist
08.2020 - 01.2022
Customer Solutions Agent
08.2018 - 07.2020
Duncanville High School
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