Crystal Martinez

• Investigate suspected fraud, waste, and abuse related to medical and dental claims.

• Review documentation, provider patterns, x-rays, charts, and EOBs for billing irregularities.

• Reviewed dental and medical records to verify billing accuracy, identifying potential fraud and ensuring compliance with state regulations

• Responsible for overseeing the day-to-day operations of the team, making sure they are adhering to their responsibilities and making sure motivation and performance levels are maintained.
• Supervised a team of 14 individuals to ensure that excellent customer service was being provided to our consumers and providers
• Coach individuals on Qualities, Metrics to improve team productivity and efficiency
• Responsible for any escalated issues pertaining to members or providers to resolve in a timely manner
• Pulls FCR reports to ensure accuracy of outstanding issues, Worked various special projects
• Review Daily metrics for agents to ensure monthly goal is being met, conduct side by side coaching with the team to provide mentoring feedback for growth

• Assist Medical Providers calling in regarding Member Eligibility, Benefits, Claims in a friendly and efficient matter
• Trained in various groups, APWU, Select Health, Pequot, BPA, Health New England and in various systems to efficiently adhere to calls
• Meeting standard team and Individual Expectations, and assist fellow peers in chat communication and give 100% participation with team meetings
• Aim to provide the highest level of customer service by remaining organized, punctual and accurate

• Worked Various Dental Cases per day in an efficient matter while exceeding Quality and Monthly goal
• Proficient with working Various applications Salesforce, Facets, Skygen and Isel Cases
• Maintain consistent attention to the Providers Request and maintained information accurate as well as multitasking
• Ensured to meet and comply to case deadlines, maintained log of current and completed work from high priority workloads

• Worked Various high level aged Claims, Inpatient Acute, Outpatient Acute, UB, HCFA, LTAC, ARU Rehab, Home Health, Ambulance and Transportation
• Exceedingly completed over 50 claims per day meeting over Quota, while maintaining 100% Quality
• Generated reports for analysis, and responded to complex inquiries and issues, using excellent judgement and decision- making skills
• Printed letters for Authorizations and denials in correspondence to claim.
• Reviewed Claims for medical necessity determining approvals and denials, worked closely with Case Managers and Nurses for determination

• Provided Prompt Customer Support with a professional, Friendly, and patient attitude for Members calling about their Dental and Vision Benefits
• Certified Mentor assisted in various New Hire classes, Trained 15 New hires on company specific policies, procedures, and compliance guidelines
• Answered over 150 calls a day exceeding Quota by 15%
• Listened, Diagnosed, and resolved Our Members and Providers issues with step- by -step solutions
• Positive attitude received a 5- star satisfaction rating through voice chat, and email communication while exceeding in QVC