Summary
Overview
Work History
Education
Skills
Additional Information
Timeline
Generic

Carina Jaimes Cruz

Kissimmee

Summary

Detail-oriented and compassionate professional with over 5 years of experience in healthcare claims, insurance, and administrative support. Experienced healthcare and insurance representative with a strong background in Medicare, Medicaid, Dual Special Needs Plans (D-SNP), and commercial insurance. Skilled in resolving complex billing issues, reviewing claim denials, and supporting accurate reimbursement across multiple payer types. Adept at handling confidential patient data, communicating policy details, and supporting members through all stages of the claim and payment process.

Overview

12
12
years of professional experience

Work History

Sr. Service Advocate - D-SNP & C-SNP

Aetna
09.2024 - Current
  • Administers the customer service strategy to advocate for customer needs, establish key performance indicators (KPIs), and monitor team performance to ensure high-quality service delivery.
  • Maintains relationships with internal and external stakeholders to gain an in-depth understanding of customer needs and serve as a customer advocate within the organization.
  • Manages the reporting function to drive data-informed decision-making and improve service advocate operations.
  • Communicates with service advocates on escalation processes to ensure complex situations are handled appropriately.
  • Organizes service advocate teams based on workload, skill sets, and customer needs to provide adequate coverage and support during peak hours.
  • Conducts research through literature reviews and leading publications that cover topics related to customer service, call center operations, and customer experience management.
  • Coordinates cross-functional collaborations to amplify the impact of service advocacy campaigns and promote positive relationships with customers.
  • Prepares training activities for service advocate teams to align customer service strategies and messaging across touchpoints.
  • Evaluates the outcomes of service advocacy efforts to determine the direction of future campaigns.
  • Handled confidential patient data in compliance with HIPAA regulations.
  • Managed high-volume caseloads while maintaining quality standards and quick response times.
  • Acted as a liaison between clients and various departments within the company; ensured all parties were informed and aligned on pertinent matters.
  • Collaborated with cross-functional teams to ensure seamless communication and consistent service delivery.
  • Utilized CRM software effectively to track client interactions and provide detailed reports on account health/activity when required.
  • Served as the primary point of contact for Medicare/Medicaid members enrolled in Dual Special Needs Plans (D-SNP) and Chronic Special Needs Plans (C-SNP), providing high-touch support and issue resolution.
  • Completed Health Risk Assessment (HRA) surveys via phone to gather detailed health and lifestyle information, supporting the Care Management and Clinical teams in creating personalized care plans.
  • Ensured accurate documentation of HRA responses in internal systems while maintaining compliance with HIPAA and CMS regulations.
  • Identified and escalated member needs to clinical or case management teams for follow-up, including social determinants of health, medication adherence, and high-risk conditions.
  • Promoted care coordination services, preventive screenings, and wellness resources to increase member engagement and health outcomes.
  • Handled inbound and outbound calls with empathy and professionalism, maintaining high customer satisfaction and quality assurance scores.

Administrative Assistant

Tidy Shine, Inc.
04.2017 - Current
  • Managed phone and email correspondence and handled incoming and outgoing mail and faxes.
  • Surpassed team goals by partnering with colleagues to implement best practices and protocols.
  • Executed record filing system to improve document organization and management.
  • Opened and properly distributed incoming mail to promote quicker response to client inquiries.
  • Interacted with vendors, contractors and professional services personnel to receive orders, direct activities, and communicate instructions.
  • Liaised between clients and vendors and maintained effective lines of communication.
  • Facilitated timely delivery of special projects to meet organizational and departmental objectives.
  • Created and maintained databases to track and record customer data.
  • Restocked supplies and placed purchase orders to maintain adequate stock levels.
  • Built and maintained excellent customer relationships through timely response to inquiries and going above and beyond to accommodate unusual requests.
  • Supported company leaders by managing budgets, scheduling appointments and organizing itinerary.
  • Managed schedules for executives, enhancing productivity and time management.
  • Trained new staff, accelerating onboarding and integration.
  • Maintained budgets, ensuring cost-effective resource allocation.
  • Supported cross-departmental projects, fostering collaboration and success.
  • Maintained customer and vendor records, performed data entry, and processed invoices.
  • Created tracking systems for accounts receivable and supported internal audits.
  • Communicated with clients about overdue balances and provided assistance with payment options.
  • Prepared financial documents and maintained documentation for internal use and external audits.
  • Ensured accurate record-keeping with diligent data entry and database management for vital company information.
  • Promoted a positive work environment through effective communication skills and fostering professional relationships among colleagues.
  • Coordinated office supply inventory management, proactively ordering necessary items before depletion to avoid workflow disruptions.
  • Assisted with human resources tasks such as updating employee files or submitting time-off requests per company policy guidelines.
  • Optimized calendar management for executives by scheduling appointments strategically while considering priorities and minimizing conflicts.
  • Streamlined invoice processing procedures to ensure timely payment of vendors while minimizing errors in financial records.

CCR- Commercial Insurance

CVS/caremark
06.2023 - 09.2024
  • Provided accurate, valid, and complete information to customers.
  • Resolved customer complaints promptly and professionally.
  • Maintained a detailed record of all customer interactions, transactions, comments, and complaints.
  • Assisted customers in navigating through website features and functions to locate desired information.
  • Ensured compliance with company policies regarding privacy laws and data protection regulations.
  • Processed orders accurately and efficiently according to established procedures.
  • Escalated unresolved issues requiring further investigation or specialized expertise.
  • Delivered fast, friendly and knowledgeable service for routine questions and service complaints.
  • De-escalated customer issues with proven conflict mediation and problem-solving abilities.
  • Kept customer and system account information accurate and current to support timely resolutions for concerns.
  • Maintained high satisfaction score by consistently resolving first-call issues.
  • Educated customers where applicable to alleviate need for future contact.
  • Managed large volume of patient calls related to insurance coverage, billing disputes, and claims.
  • Ensured data accuracy in patient account systems and documented all communication.
  • Educated patients on billing processes.
  • Handled confidential patient data in compliance with HIPAA regulations.
  • Handled high-volume inbound calls regarding insurance claims and account status.
  • Updated account information and entered notes in CRM system.
  • Assisted customers in understanding their coverage, billing statements, and claim rejections.
  • Escalated complex billing issues to specialized teams and tracked resolution progress.
  • Provided front-line support to commercial insurance members, delivering accurate, timely, and empathetic service for inquiries related to pharmacy benefits, claims, coverage, and prior authorizations.
  • Assisted members in understanding plan details, copays, deductibles, formulary alternatives, and network pharmacy locations to promote plan adherence and satisfaction.
  • Resolved escalated concerns and complex benefit issues by navigating internal systems, coordinating with other departments, and following up through resolution.
  • Maintained detailed records of all interactions, documenting call summaries, claim details, and resolutions in compliance with HIPAA and company standards.
  • Educated members on available digital tools and self-service options to streamline prescription refills, order tracking, and account management.
  • Demonstrated deep understanding of pharmacy benefits and commercial insurance policies to guide members with confidence and accuracy.
  • Collaborated with pharmacy technicians, billing specialists, and providers to troubleshoot denied claims, initiate overrides, or facilitate prior authorizations.
  • Upheld customer satisfaction metrics by meeting quality assurance standards, average handle time, and first-call resolution goals.

Medicare Sales Agent

UHC United Healthcare
03.2021 - 04.2022
  • Determined customers' financial needs by assessing existing coverage and aligning new products and services with long-term goals.
  • Analyzed risk factors to recommend appropriate coverage levels.
  • Worked with the sales team to collaboratively reach targets, consistently meeting or exceeding personal quotas.
  • Educated clients on insurance policies and procedures.
  • Analyzed customer needs to provide customized insurance solutions.
  • Expanded client base by diligently prospecting new leads and effectively presenting product offerings.
  • Increased sales revenue by consistently meeting and exceeding sales targets.
  • Improved overall customer satisfaction by promptly addressing concerns and providing tailored solutions.
  • Identified new areas of opportunity within existing accounts by offering additional products or services based on their needs analysis results.
  • Delivered engaging sales presentations tailored specifically towards individual client needs, demonstrating a deep understanding of their business and industry.
  • Enhanced product knowledge through continuous training and professional development opportunities.
  • Educated clients on insurance products, enabling them to make informed decisions regarding their coverage needs.
  • Educated prospective and existing clients on Medicare Advantage, Medicaid, Dual Special Needs Plans (D-SNP), and Prescription Drug Plans (PDP) to ensure optimal coverage selection based on health and financial needs.
  • Conducted eligibility verification and needs assessments to match members with the most appropriate insurance plans available in their area.
  • Assisted clients in completing applications, gathering required documentation, and navigating enrollment processes in compliance with CMS guidelines.
  • Met and exceeded monthly and quarterly sales targets through consistent outreach, lead follow-up, and superior customer service.
  • Maintained detailed and accurate records of all client interactions, enrollments, and follow-ups using CRM systems and compliance software.
  • Collaborated with internal teams to stay updated on product changes, market trends, and regulatory updates impacting plan offerings and eligibility.
  • Built trust-based relationships with a diverse client base, including seniors and individuals with chronic conditions or limited income.

Custody Officer

Wellpath
09.2019 - 03.2021
  • Provides security functions within and around the perimeter of the facility.
  • Conducted physical searches of prisoners and premises in search of weapons and contraband.
  • Responded to emergency situations and de-escalated hostile confrontations.
  • Made rounds at specified intervals and conducted head counts and roll calls.
  • Enforced rules and regulations to maintain order among inmates.
  • Attended to feeding, housing, and physical well-being of inmates.
  • Prepared reports to document incidents and violations.
  • Documented inmate behavior and activities in logbooks.
  • Established positive working relationships and maintained boundaries with resident offenders.
  • Wrote daily reports and maintained logs of inmate activities and behaviors.
  • Transported prisoners throughout facility and off-site to medical appointments and court appearances.
  • Searched building and grounds, living quarters, and work areas for contraband.
  • Conducted security checks of inmates and living areas.
  • Supervised visitation activities between inmates and their visitors while maintaining security and order throughout interactions.
  • Developed rapport with inmates, fostering mutual respect that contributed to overall facility stability.
  • Maintained accurate records of inmate behavior, documenting incidents as needed for further action or review.
  • Collaborated with other officers to maintain order and enforce disciplinary measures when necessary.

Correctional Officer

Homestead CI
08.2018 - 09.2019
  • Care, custody, and control of inmates
  • Searched cells of inmates to identify and confiscate contraband and other prohibited items.
  • Investigated and responded to incidents of inmate misconduct.
  • Provides security functions within and around the perimeter of the facility.
  • Conducted physical searches of prisoners and premises in search of weapons and contraband.
  • Responded to emergency situations and de-escalated hostile confrontations.
  • Made rounds at specified intervals and conducted head counts and roll calls.
  • Enforced rules and regulations to maintain order among inmates.
  • Attended to feeding, housing, and physical well-being of inmates.
  • Prepared reports to document incidents and violations.
  • Documented inmate behavior and activities in logbooks.
  • Established positive working relationships and maintained boundaries with resident offenders.
  • Wrote daily reports and maintained logs of inmate activities and behaviors.
  • Searched building and grounds, living quarters, and work areas for contraband.
  • Conducted security checks of inmates and living areas.

Tutor

America Reads
08.2016 - 04.2018
  • Administered standardized tests to assess student strengths and weaknesses.
  • Motivated students with accurate feedback and positive reinforcement.
  • Used personalized learning plans to guide students to deeper understanding of course material and learning styles.
  • Mentored and coached students with focus on developing independence and self-confidence.
  • Conducted group tutoring sessions to help students engage active learning and critical thinking skills.
  • Collaborated with teachers, administrators and parents to determine how best to support student success.
  • Conducted review sessions to help students prepare for tests.
  • Monitored student progress and provided feedback and support.
  • Assessed student learning needs and provided relevant instruction to close knowledge gaps.
  • Maintained records of student assessments, tutoring activities and results.
  • Worked closely with students on specific class struggles, closely reviewing materials and assignments to offer targeted help.

Certified Nursing Assistant

Coral Gables Hospital
03.2016 - 08.2016
  • Evaluated patients to identify and address wounds, behavioral concerns, and medically relevant symptoms.
  • Documented patient information and care activities in electronic health record.
  • Answered call lights and supported patient comfort and safety by adjusting bed rails and equipment.
  • Delivered high-quality care to patients in hospital facility.
  • Maintained patient stability by checking vital signs and weight and recording intake and outtake information.
  • Transported patients between rooms and appointments or testing locations.
  • Assisted nursing staff with completing daily rounds, documenting vital signs and answering calls.
  • Facilitated personal hygiene management, feeding and ambulation.
  • Changed linens in rooms, keeping spaces fresh and clean for patient health and satisfaction.
  • Responded to patient requests for supplies and personal comfort items such as extra blankets.
  • Maintained accurate documentation in electronic health records.
  • Handled confidential patient data in compliance with HIPAA regulations.
  • Maintained a clean, safe environment by sanitizing surfaces, changing linens, and disposing of waste properly.
  • Improved patient care quality by monitoring and recording vital signs, fluid intake, and output.
  • Reduced fall incidents by implementing safety measures like bed alarms and proper positioning techniques.
  • Prevented pressure ulcers development through frequent turning, repositioning of patients, and diligent skin assessments.
  • Enhanced team efficiency by promptly responding to call lights and reporting changes in patient condition to nurses.
  • Conducted regular rounds to monitor patients' physical and mental status throughout shifts.
  • Utilized therapeutic communication, empathy and active listening skills to encourage and develop positive relationships with patients.
  • Performed accurate documentation of patient information according to established protocols for record-keeping purposes.
  • Assisted nurses with wound care procedures ensuring proper healing processes took place.
  • Streamlined communication between nursing staff, patients, and families to ensure comprehensive understanding of care plans.
  • Served as an advocate for each patient's needs during shift handoffs or interdisciplinary conferences with other healthcare professionals.

Shift Manager

McDonalds
11.2014 - 02.2016
  • Cooperated with coworkers to improve customer experience and manage storefront.
  • Established team priorities, maintained schedules and monitored performance.
  • Launched quality assurance practices for each phase of development
  • Coached crew members to optimize performance and motivate toward more efficient work.
  • Used industry expertise, customer service skills and analytical nature to resolve customer concerns and promote loyalty.
  • Trained and mentored new employees to maximize team performance.
  • Worked closely with team members to schedule breaks and shifts to meet state regulations.
  • Established performance goals for employees and provided feedback on methods for reaching those milestones.
  • Consistently exhibited calm demeanor during periods of high volume or unusual events to keep store operating smoothly and set positive example for shift team.

Tutor

America Reads
11.2013 - 04.2015
  • Administered standardized tests to assess student strengths and weaknesses.
  • Motivated students with accurate feedback and positive reinforcement.
  • Used personalized learning plans to guide students to deeper understanding of course material and learning styles.
  • Mentored and coached students with focus on developing independence and self-confidence.
  • Conducted group tutoring sessions to help students engage active learning and critical thinking skills.
  • Collaborated with teachers, administrators and parents to determine how best to support student success.
  • Conducted review sessions to help students prepare for tests.
  • Monitored student progress and provided feedback and support.
  • Assessed student learning needs and provided relevant instruction to close knowledge gaps.
  • Maintained records of student assessments, tutoring activities and results.
  • Worked closely with students on specific class struggles, closely reviewing materials and assignments to offer targeted help.

Education

Bachelor of Arts - Healthcare Services Administration

Florida International University
Miami, FL
05.2018

Associate of Arts - Pre-Nursing in Nursing

Miami Dade College
Homestead, FL
01.2015

High School Diploma - undefined

Miami Community Charter School
Homestead, FL
01.2013

Skills

  • Staff Training
  • Call Control
  • Customer Retention Abilities
  • Product and Service Knowledge
  • Customer Assistance
  • Problem-Solving Skills
  • Documentation and Recordkeeping
  • Study Material Development
  • Client Needs Assessment
  • Information Updates
  • Enrollment Assistance
  • Customer Relations
  • Tutoring and Student Assistance
  • Curriculum Review and Lesson Preparation
  • Computer Proficiency and Microsoft Office
  • Organization and Planning Skills
  • Team Leadership
  • Staff Management
  • Verbal and Written Communication
  • Managing Cash Register
  • Productivity Performance
  • Managing Appointments
  • Coaching and Mentoring
  • Cross-Functional Team Management
  • Employee Training
  • Time Management
  • Finance and Accounting Operations
  • Issue and Conflict Resolution
  • Overseeing Employees
  • Administration and Reporting
  • Account Management and Updating
  • Managing Multiple Tasks
  • Timelines and Milestones
  • Service Quality
  • Efficient Data Entry
  • Administrative Support
  • Office Supplies and Inventory
  • Maintaining Quality Assurance Standards
  • Administrative expertise
  • HIPAA
  • Healthcare industry
  • Insurance eligibility verification
  • Insurance claims review
  • Insurance product knowledge
  • Insurance data processing
  • Data entry and recordkeeping
  • Data entry skills
  • Medical data entry

Additional Information

  • Additional Information
  • Dean List (Spring 2017- Fall 2017)

Timeline

Sr. Service Advocate - D-SNP & C-SNP

Aetna
09.2024 - Current

CCR- Commercial Insurance

CVS/caremark
06.2023 - 09.2024

Medicare Sales Agent

UHC United Healthcare
03.2021 - 04.2022

Custody Officer

Wellpath
09.2019 - 03.2021

Correctional Officer

Homestead CI
08.2018 - 09.2019

Administrative Assistant

Tidy Shine, Inc.
04.2017 - Current

Tutor

America Reads
08.2016 - 04.2018

Certified Nursing Assistant

Coral Gables Hospital
03.2016 - 08.2016

Shift Manager

McDonalds
11.2014 - 02.2016

Tutor

America Reads
11.2013 - 04.2015

Associate of Arts - Pre-Nursing in Nursing

Miami Dade College

High School Diploma - undefined

Miami Community Charter School

Bachelor of Arts - Healthcare Services Administration

Florida International University

Similar Profiles

CREATE PROFILE