CECELIA WALTON-JONES
Sun City,FL
Summary
Detail-oriented Tier 1 Claims Representative with 4+ years in Medicare health plans. Expertise in claims research, Durable Medical Equipment, and prescription drug coverage, including Medicare Parts A, B, and D. Proven ability to investigate inquiries, clarify benefits, document findings, and resolve concerns efficiently in high-volume settings.
Overview
20
20
years of professional experience
Work History
Tier 1 Claims Representative / Customer Service Associate
Maximus Federal Services
Riverview, FL
06.2022 - Current
- Providing Tier 1 claims and member service support for Medicare health plan members in a high-volume contact center environment.
- Research and investigate Medicare claims to assist members with claim-related questions, concerns, and resolution.
- Support members with questions concerning Medicare Parts A, B, and D and Medicare Advantage plans.
- Review available claim and member information to research inquiries and provide accurate, understandable explanations.
- Explain health plan and claim information to members using clear, respectful, and easy-to-understand communication.
- Apply active listening, critical thinking, and problem-solving skills when addressing complex member concerns.
- Conduct claims research involving Durable Medical Equipment (DME) and prescription drug coverage.
- Handle 60+ calls daily, balancing call volume with accuracy, professionalism, and quality customer service.
- Support service-quality initiatives designed to improve efficiency, reduce wait times, and enhance the member experience.
Collections Representative
Santander Consumer USA
Tampa, FL
01.2021 - 04.2022
- Managed 120 inbound customer calls daily in high-volume financial services contact center, ensuring efficient service delivery and customer satisfaction.
- Reviewed customer accounts, researched account information, and addressed inquiries about balances and payment options to facilitate informed customer decisions.
- Reviewed customer accounts, researched account information, and addressed questions regarding balances and payment options.
- Handled difficult customer situations with patience, professionalism, and a solution-focused approach.
- Used skip-tracing resources to locate customers and update account information.
- Maintained accurate documentation of customer contacts and account activity to support compliance and operational integrity.
Caregiver
Spirit Soul Body Home Care LLC
Tampa, FL
03.2019 - 02.2020
- Provided compassionate personal care and daily living assistance to clients.
- Provided grooming, dressing, meal preparation, medication reminders, errands, laundry, and household assistance to support daily living.
- Cultivated strong relationships with clients to deliver emotional support and companionship.
- Monitored client needs to ensure safety, comfort, and overall well-being.
Caregiver
Home Health Care
Tampa, FL
02.2014 - 01.2019
- Delivered personal care and daily living assistance to two terminally ill family members, ensuring comfort and dignity.
- Supported grooming, dressing, meal preparation, medication reminders, and personal care needs, enhancing daily quality of life.
- Provided companionship, emotional support, and respectful care to individuals with significant health-care needs.
- Fostered companionship and emotional support for individuals with significant health-care needs, promoting mental well-being.
Senior Admissions Representative
Everest University Online
Tampa, FL
12.2006 - 11.2013
- Executed 40–60 outbound calls daily to generate referrals and connect prospective students with relevant resources, enhancing engagement.
- Managed 80+ inbound calls, delivering accurate information and professional assistance to prospective students, ensuring a positive experience.
- Answered questions, identified customer needs, and provided individualized solutions.
- Addressed inquiries, assessed customer needs, and offered tailored solutions, facilitating informed decision-making for prospective students.
- Maintained high-quality customer service while managing a demanding call volume.
Education
Some College - Real Estate Coursework
Tampa School of Real Estate
Tampa, FLSurety Agent -
Hillsborough Community College
Tampa, FLCertified Nursing Assistant -
Erwin Technical College
Tampa, FLHigh School Diploma -
Tampa Bay Tech High School
Tampa, FLSkills
- Tier 1 Claims Support
- Claims resolution
- Claims research
- Claims adjudication
- Medicare Claims Research
- Medicare Parts A, B & D
- Member Services
- Durable Medical Equipment (DME)
- Prescription Drug Coverage
- Benefits & Coverage Research
- Health Plan Customer Service
- Member Services
- High-Volume Call Center
- Data Entry & Documentation
- Claims Documentation
- Customer Relationship Management
- Inbound & Outbound Calling
- Quality Assurance
- Account management
- Problem Resolution
- Confidential Member Information
- Medicare guidelines
- Benefit verification
- Benefit verification
Personal Information
Title: MEDICARE CLAIMS REPRESENTATIVE | MEMBER SERVICES | HEALTH PLAN CUSTOMER SERVICE
Timeline
Tier 1 Claims Representative / Customer Service Associate
Maximus Federal Services
06.2022 - Current
Collections Representative
Santander Consumer USA
01.2021 - 04.2022
Caregiver
Spirit Soul Body Home Care LLC
03.2019 - 02.2020
Caregiver
Home Health Care
02.2014 - 01.2019
Senior Admissions Representative
Everest University Online
12.2006 - 11.2013
Some College - Real Estate Coursework
Tampa School of Real Estate
Surety Agent -
Hillsborough Community College
Certified Nursing Assistant -
Erwin Technical College
High School Diploma -
Tampa Bay Tech High School