Crystal Edwards
Miami,FL
Summary
Results-driven individual with a solid track record in delivering quality work. Known for excellent communication and teamwork abilities, with a commitment to achieving company goals and delivering exceptional service. Passionate about continuous learning and professional development.
Overview
4
4
years of professional experience
1
1
Certification
Work History
Senior Customer Service Representative
Meritain Health an Aetna
Miami, FL
08.2021 - Current
- Responded promptly to inquiries from customers about products or services.
- Provided customer service by answering inquiries, resolving complaints, and providing general information to clients regarding healthcare services.
- Maintained client confidentiality according to HIPAA regulations at all times.
- Utilized active listening and communication skills to address customer inquiries and escalate issues to supervisor.
- Handled high volume of incoming calls, providing exceptional customer service to patients and families.
- Reviewed eligibility responses to assess patient benefit level and prepare estimates.
- Assisted in the implementation of new technologies and processes to improve patient access services.
- Addressed patient inquiries and concerns, resolving issues in a timely and empathetic manner.
- Promoted high customer satisfaction by resolving problems with knowledgeable and friendly service.
- Resolved customer queries related to health insurance claims, payments, reimbursements.
- Verified insurance coverage and eligibility for services provided.
- Researched policy provisions to determine coverage levels, limitations, and exclusions.
- Assessed denials based on established criteria and procedures.
- Stayed current on HIPAA regulations, benefits claims processing, medical terminology and other procedures.
- Checked into questionable claims, interviewing agents and claimants to resolve errors and omissions.
- Responded to inquiries from members regarding their health care benefits.
- Assisted with resolving billing disputes between providers and insurers.
- Resolved complex discrepancies in policyholder files to facilitate accurate claim processing.
- Reviewed and verified claim information to ensure accuracy of data and compliance with established policies.
- Provided quality customer service to assigned, insured and claimants throughout claims process to deliver timely service to customers.
- Verified details with policyholders and requested additional information.
- Delivered quality customer service to assigned, insured and claimants throughout entire claims lifecycle to promote service times.
- Assisted claimants, providers and clients with problems or questions regarding claims.
- Assisted new policyholders with processing claims.
- Documented changes in claim statuses using specialized software systems.
- Used insurance rate standards to calculate premiums, refunds, commissions and adjustments.
- Represented the insurer at hearings or mediations when necessary.
- Researched discrepancies between provider-submitted documentation and payer requirements.
- Monitored and responded quickly to requests received through the IT help desk ticketing system.
- Assisted customers with password resets, account unlocks, and security settings adjustments.
- Conducted remote diagnostics to identify and solve technical problems.
- Analyzed trends in denials or rejections of claims due to lack of proper authorization.
- Maintained detailed documentation of all activities related to the precertification process.
- Utilized various software applications such as electronic medical record systems for data entry purposes.
- Transmitted medical records and other correspondence by mail, e-mail, or fax.
- Conversed with people from different cultures daily, providing high level of respect and patience with each interaction.
Education
Associate of Science - Health Services Management
Broward College
Fort Lauderdale, FL12-2025
Skills
- Customer relations
- Organization
- Data entry
- Public speaking
- Clerical support
- Microsoft Word
- Data management
- Task prioritization
- Friendly, positive attitude
- Active listening
- Problem resolution
- MS office
- Attention to detail
- First Aid/CPR
- Multitasking Abilities
Certification
- Technical Certificate in Accounting Technology Specialist
- Certificate in Fundamentals Of Written Communication
- Phlebotomy Certificate
- Ekg Certificate
References
References available upon request.
Timeline
Senior Customer Service Representative
Meritain Health an Aetna
08.2021 - Current
Associate of Science - Health Services Management
Broward College
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