Aleyda Abreut
Miami,Florida
Summary
Talented in international health insurance operations, with 27 years of experience. Excellent verbal and written skills in English and Spanish. Able to work in a multi-ethnic, and multi-cultural environment. Strong knowledge of the Microsoft Office product suite (Word, Excel, PowerPoint, and Access). Excellent interpersonal skills, as well as being a team player. Available for travel. Motivational leader and organizational problem-solver with advanced supervisory, team-building, and customer service skills. Experience stepping into roles and quickly making positive changes to drive company success. Focused on using training, monitoring, and morale-building techniques to maximize employee engagement and performance.
Overview
27
27
years of professional experience
1
1
Certification
Work History
Claims & Customer Service Manager
Global Reach Health
Miami, FL
04.2020 - Current
- Revise daily departmental priorities (CS), assign resources, and create work schedules accordingly. Maintain an appropriate staffing level, supervise the daily activities, and prioritize the workload of Customer Services so that daily and weekly departmental deadlines are met.
- Measures team members' performance against key performance indicators, evaluates and performs performance feedback, while taking appropriate actions necessary to maintain optimal performance, including disciplinary actions as required. Conducts employee performance evaluations for the company’s annual and mid-year performance appraisals. Provide management and professional guidance to team members through regular one-on-one meetings, regular team meetings, and performance goals.
- Manages time and attendance for direct reports.
- Completes basic quality control audits that allow for the review of at least 5% of the activities completed by the Customer Service and Claims Processing team.
- Ensures that cases are solved in a timely manner, in compliance with policy and company provisions. Manages escalated cases up to resolution, working directly with various departments, providers, customers, and agents as necessary. Escalates cases to the Medical Director as needed.
- Coordinate and/or provide support and training for associates, managers, and others as needed.
- Documents processes and creates/updates manuals where appropriate, including TPA guidelines.
- Creates documentation of trends and logs processes and potential issues to share with the Management Team.
Senior Appeals & Quality Control Specialist
Bupa Latin America
Miami, USA
07.2015 - 03.2020
- For Quality Control and Resolutions Team
- Indentifies deviations from establish procedures and policies, identifies root cause issues and develops the appropriate action plans for resolution
- Makes decision for the delivery of quality service under own initiative
- Sets goals, directives and monitors department progress in agreement with administration
- Reviews teams reports and production, monitors pending claims and distributes work as per needs arises
- Audits quality control production and determines opportunities for improvement
- Oversees quality reviews to ensure sustained claim quality
- Trains, coaches and motivates staff to ensure optimized performance as well as other teams
Subject Matter Expert, CRM
Bupa Latin America
Miami, USA
06.2018 - 10.2019
- Responsible for testing new system functionality before being released to production
- Developed and conducted trainings related to new system functionality and reported training effectiveness., including traveling to Dominican Republic and Mexico
- Produced training materials and additional auxiliary documentation for system users
Appeals and Grievance Analyst
Bupa Latin America
Miami, USA
08.2011 - 07.2015
- Utilizes guidelines and review tools to conduct extensive research and analyze appeals, complex cases, complaints and extraordinary benefits to present to the appeals committee for resolution
- In charge of tracking possible fraudulent activity, properly presenting and documenting in order to prevent future cases
- Served as a liaison between the appeals committee and other internal departments while maintaining an understanding of their functions to insure effective delivery of customer service as per their expectations
Customer Service Representative & Account Manager
Bupa Latin America
Miami, USA
04.2007 - 04.2011
- Handled incoming calls, e-mails and correspondence
- Complaint Handling within 24 hour turn around time Improvement on customer satisfaction
- Review and analyze reports in claims and policies for our top agents
- Proactively calling producers to verify service was meeting expectations
- Act as host to the visits of producers and clients when visiting to the Miami office
Claims Processor
Bupa Latin America
Miami, USA
01.2004 - 11.2006
- Responsible for the processing of medical claims, guaranteeing accuracy, according to policy provisions
- Point of reference for claim system trouble shooting
Medical Coordinator
Bupa Latin America
Miami, USA
01.2002 - 11.2004
- Responsible for attending to agents, members and providers office visits as well as correspondence while providing a solution to their issues
- Provided support to all local offices while keeping them informed new information release
- Ensure all authorization letters were sent on time
- Guarantee turnaround time is being met with the workload
- Discuss and present cases in big claims meetings
- Do appropriate follow up with all cases to ensure client/agent are informed and well serviced
- Maintain clear communications with all customers and agents
- Provide Excellent Service to clients and agents to ensure a great customer experience
Claims Coordinator
Bupa Latin America
Miami, USA
08.1998 - 10.2002
- Managed phone calls, e-mails, correspondence related to claims for top agents
- Act as host to the visits of producers and clients when visiting to the Miami Office for all their related claims
Education
Green Belt Certified -
Florida International University
Miami, FLSkills
- Quality Control
- Research
- Administrative support
- Complaint resolution
- Account management
- Customer focused
- Skilled multi-tasker
- Tactful and diplomatic
- Escalation handling
- Workflow management
- Problem-solving
- Customer relationship management (CRM)
- Deadline oriented
References
References Available upon request.
Certification
- Green Belt
Timeline
Claims & Customer Service Manager
Global Reach Health
04.2020 - Current
Subject Matter Expert, CRM
Bupa Latin America
06.2018 - 10.2019
Senior Appeals & Quality Control Specialist
Bupa Latin America
07.2015 - 03.2020
Appeals and Grievance Analyst
Bupa Latin America
08.2011 - 07.2015
Customer Service Representative & Account Manager
Bupa Latin America
04.2007 - 04.2011
Claims Processor
Bupa Latin America
01.2004 - 11.2006
Medical Coordinator
Bupa Latin America
01.2002 - 11.2004
Claims Coordinator
Bupa Latin America
08.1998 - 10.2002
Green Belt Certified -
Florida International University
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