CHELSEA RODRIGUEZ
San Antonio,TX
Summary
Senior Customer Service Representative supporting members, providers, and internal partners across benefits, claims, billing, referrals, and prior authorizations. Resolves escalated service issues through root cause analysis, claim adjustments, and regulatory review across commercial, Medicare, and Medicaid plans. Coaches peers, supports onboarding, and documents workflow improvements that strengthen service quality and operational efficiency.
Overview
15
15
years of professional experience
Work History
Senior Customer Service Representative
UHC Specialty & Individual Operations
07.2019 - Current
- Managed [number] member inquiries weekly regarding benefits, eligibility, billing, and healthcare coverage, ensuring accurate information delivery.
- Investigate escalated service issues through root cause analysis and communicate clear resolutions to members and partners.
- Manage referrals and prior authorizations, including intake, notifications, and utilization review for timely processing.
- Review dental claims and pre-authorizations while applying company policies and compliance requirements consistently.
- Assisted providers, hospitals, clinics, and clinical teams in resolving claims and authorization questions efficiently, enhancing service delivery.
- Coached peers and documented workflow improvements, reinforcing onboarding processes and promoting team consistency.
Intern
Family Service Association
01.2019 - 05.2019
- Processed [number] intake forms weekly to facilitate client enrollment and ensure accurate record-keeping.
- Verified client information and organized paperwork to streamline enrollment and maintain updated records.
- Managed documentation workflows by filing completed materials and routing information to relevant internal teams.
- Managed documentation workflows, filing completed materials and routing information to the appropriate internal teams.
Digital Commerce Representative
Kohl's
11.2011 - 06.2016
- Achieved first-call resolution to enhance customer satisfaction and minimize repeat contacts.
- Processed billing inquiries and payment transactions accurately in fast-paced service environment.
- Documented customer interactions and account activities for effective follow-up.
Education
Associate of Arts - Criminal Justice
Northwest Vista College
Skills
- Claims & Benefits Administration
- Medicare claims processing
- Dental claims processing
- Benefits & eligibility verification
- Claims resolution
- Provider Authorization & Relations
- Referrals & prior authorizations
- Utilization review
- Provider relations
- Healthcare operations
- Operations improvement
- Process improvement
- Performance metrics analysis
- Operational reporting
- Workflow documentation
- Service Recovery and Coaching
- Grievances & appeals
- Training & mentoring
- Call coaching
- Escalation handling
- NEA
System Applications
Proficient in utilizing a wide range of dental and healthcare operations systems and including ACET, Dental Facets, Doc360, NEA, DentalExchange, MyMetrics, IEX, ETS, Nice Quality Central, Amazon Connect, Genesys and Print 2 Fax to support claims research, provider services, appeals, grievances resolution benefit's verification and operational reporting.
Timeline
Senior Customer Service Representative
UHC Specialty & Individual Operations
07.2019 - Current
Intern
Family Service Association
01.2019 - 05.2019
Digital Commerce Representative
Kohl's
11.2011 - 06.2016
Associate of Arts - Criminal Justice
Northwest Vista College