Carla Toro
Jacksonville
Summary
To obtain a challenging position utilizing my exceptional problem solving, relationship building
and exemplary customer service experience within an upwardly mobile organization, which
allows room for personal growth and development.
Summary of Qualifications:
Over five years of extensive customer service experience in the health care industry. Results-
oriented, analytical problem solver. Key competencies include team development, continuous
improvement and attention to detail. Demonstrated ability to identify, recommend and implement
strategies conducive to team enhancement, customer satisfaction and improve business results.
Overview
19
19
years of professional experience
Work History
Benefits Administrator Advocate and Public Risk Management Representative Service
BlueCross BlueShield of Florida
01.2008 - 01.2010
- Advocate III
- Provide service and support to Benefit Administrators/Decision Makers for major groups (300 plus contracts each group)
- Service Groups and Benefits Administrators on complex claims and inquiries
- Serve as Liaison between Benefits Administrators and front line staff
- Work with Operations Analyst to ensure correct benefits information is loaded on ICB files
- Service PRM in all aspects from benefits to claims etc
- For over 40 divisions this group offers.
Customer Service and Member, Service Manager
05.2008 - 08.2008
- And
- Service Coach
- Featured in the Service Organization’s Source Magazine for Outstanding Customer Service
- Six Sigma Yellow Belt Certification
- Letters of Commendation from ASO Group(s)
- Cross trained in BlueOptions Product 10/08
- Served in the walk in center from, Currently serving in a Senior Role for all lines of business in the contact center
Service Associate III
Blue Cross & Blue Shield of Florida
01.2003 - 01.2007
- Group Champion, Major Accounts
- Service Advocate III
- Provide service and support to Benefit Administrators for major groups
- Service Groups and Benefits Administrators on complex claims and inquiries
- Serve as Liaison between Benefits Administrators and front line staff
- Work with Operations Analyst to ensure correct benefits information is loaded on ICB files
- Trained frontline staff on Major Accounts and Local Group specifics
- Make out bound calls to business partners, providers and Benefits Administrators to research and resolve customer’s inquiries
- Develop and maintain relationships internal and external with agents both orally and through written to achieve high levels of customer satisfaction
- Actively participated on various teams and workgroups designed to identify and implement process improvement in the Operations area
- Handles escalated calls which normally results in successful outcomes
- Identify discrepancies in contract benefits and performs analysis to bring about resolutions
- Developed and maintains business relationships with internal departments such as Sales,
- Membership and Billing, OPL, Senior Solutions and Direct Under 65
- Inform and educate members on MyBlueService, ICB and Claims processing
- Extensive knowledge of RBMS, ITS, Prime Therapeutics, Seibel, Diamond, IMS, ICS,
- TSO, Convergence X, EIP, Claims Repository, Imaginator and Client Letter
- Working knowledge of CMCA, Quest, FGMS, Diamond, and Siebel
- Extensive knowledge with all PPO BlueChoice products, BlueOptions, HMO and
- Medicare Supplement plans
- Excellent PC skills including Microsoft Office (Word, Excel, PowerPoint, and Outlook)
- Knowledgeable on various compliance guidelines including HIPAA, ERISA, AHCA,
- NCQA and CMS
- Knowledgeable on claim details such as Reopens, Adjustments, Suspense, Diamond
- Accumulators and Patient Master
- Support the Member Service Organization Walk-In Center by handling members issues on a one on one and face to face basis
- Participated and trained individuals on the IMA Project Team and learned how to submit tickets through the Service Center
- Educate group policy members on Appeals guidelines and timeframes and direct policyholders on Extra Mile program.
Account Advocate
Florida Blue - Blue Cross Blue Shield Of Florida
01.2010 - 08.2021
- Analyzed customer feedback to identify areas for improvement.
- Maintained up-to-date knowledge of industry trends and regulations to better serve clients'' needs.
- Managed a diverse portfolio of accounts, ensuring accurate tracking and monitoring of transactions.
- Devised innovative solutions tailored specifically for each client''s unique circumstances while adhering strictly within regulatory guidelines.
- Provided exceptional customer service by addressing client inquiries promptly, maintaining high levels of satisfaction.
- Conducted regular account reviews to assess performance, identifying areas for improvement and potential growth opportunities.
- Enhanced client satisfaction with proactive problem-solving and timely resolution of account issues.
- Ensured compliance with all industry regulations and internal policies during day-to-day operations, maintaining the highest standards of professionalism.
- Developed strong relationships with clients to foster loyalty and trust, leading to increased business opportunities.
- Supported colleagues on various projects as needed ensuring seamless collaboration towards shared goals.
- Delivered exceptional customer service to every customer by leveraging extensive knowledge of products and services and creating welcoming, positive experiences.
- Met customer call guidelines for service levels, handle time and productivity.
- Followed up with customers about resolved issues to maintain high standards of customer service.
- Collaborated with staff members to enhance customer service experience and exceed team goals through effective client satisfaction rates.
- Identified and resolved discrepancies and errors in customer accounts.
Benefits Specialist
Florida Blue - Blue Cross Blue Shield Of Florida
02.2010 - 08.2021
- Resolved issues and inquiries from plan participants regarding health and welfare benefits and deductions through telephone, email, and in-person interactions.
- Explained benefits to plan participants in easy to understand terms in order to educate each on available options.
- Assisted in resolving complex benefits issues, leading to increased employee satisfaction and retention rates.
- Processed employee life event changes, ensuring timely updates to benefits and coverage for qualifying events such as marriage or the birth of a child.
- Performed benefits audits to identify discrepancies and opportunities for improvement in plan design or administration.
- Built relationships with vendors to foster quality service delivery.
- Conducted annual open enrollment sessions to ensure employees were well-informed about their options and plan changes.
- Participated in annual benefit plan review meetings with senior leadership, providing data-driven insights and recommendations for future plan design adjustments.
- Managed COBRA compliance, ensuring timely notifications and accurate administration for former employees.
- Conducted regular audits of benefits administration to comply with regulations and identify areas for improvement.
- Advocated for employees during benefits claim disputes, securing rightful coverage.
- Streamlined and monitored quality programs to alleviate overdue compliance activities.
- Planned, created, tested and deployed system life cycle methodology to produce high quality systems to meet and exceed customer expectations.
- Leveraged data and analytics to make informed decisions and drive business improvements.
- Identified and communicated customer needs to supply chain capacity and quality teams.
- Reduced waste and pursued revenue development strategies to keep department aligned with sales and profit targets.
- Assisted in organizing and overseeing assignments to drive operational excellence.
- Trained personnel in equipment maintenance and enforced participation in exercises focused on developing key skills.
- Defined clear targets and objectives and communicated to other team members.
- Used industry expertise, customer service skills and analytical nature to resolve customer concerns and promote loyalty.
- Coordinated with sales team to develop service packages that aligned with customer needs, driving additional revenue.
- Led team to enhance customer service quality, resulting in significant improvement in customer satisfaction surveys.
- Monitored team performance, adhered to service level agreements (SLAs) and provided detailed job training.
Education
High School Diploma - undefined
Sandalwood High School
Florida Community College
Jacksonville, FloridaTimeline
Benefits Specialist
Florida Blue - Blue Cross Blue Shield Of Florida
02.2010 - 08.2021
Account Advocate
Florida Blue - Blue Cross Blue Shield Of Florida
01.2010 - 08.2021
Customer Service and Member, Service Manager
05.2008 - 08.2008
Benefits Administrator Advocate and Public Risk Management Representative Service
BlueCross BlueShield of Florida
01.2008 - 01.2010
Service Associate III
Blue Cross & Blue Shield of Florida
01.2003 - 01.2007
High School Diploma - undefined
Sandalwood High School
Florida Community College
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