Delilah Perez
Leesburg,FL
Summary
Experienced Claims Agent with substantial background in the insurance industry. Possess strong analytical skills and knowledge of claim processing, policy interpretation, and customer service. Known for resolving complex claims quickly, minimizing company risk, and ensuring customer satisfaction. Have contributed to improved efficiency in past roles by streamlining processes and optimizing workflows.
Overview
15
15
years of professional experience
1
1
Certification
Work History
Claims Agent
Ascension Smart Health Plan
10.2021 - Current
- Delivered exceptional service, achieving 100% customer satisfaction by effectively addressing complaints and resolving claims issues
- Managed an average of 50+ calls per day, exceeding targets by 15%
- Ensured accuracy through thorough verification of medical coding, adhering to ICD-10 and CPT guidelines to uphold compliance and minimize financial discrepancies
- Collaborated with various internal departments to code billable items accurately for reimbursement and coordinated with internal staff to gather necessary information for billing processes
- Identified and processed overpayments, efficiently determining refund eligibility and ensuring timely resolutions
- Reviewed and responded to escalated internal and external communications from participants, providers, and provider representatives, maintaining strong relationships and clear communication
- Investigated and resolved complex claims issues through comprehensive research of provider appears and resubmitted claims, ensuring accurate processing
- Utilized FACETS software to maintain administrative functions, billing and claims processing, and patient care
- Adhered to established quality and production standards, consistently delivering results in a fast-paced environment
Customer Service Supervisor
Affinity Health Plan
Bronx, NY
12.2013 - 11.2018
- Supervised and mentored a team of 20+ customer service agents, fostering high performance and professional development, resulting in a 95% Automatic Call distribution (ACD) performance
- Compiled and analyzed customer and provider insight reports, inputting 10,000+ units of sensitive data to inform operational strategies
- Monitored key performance indicators (KPIs) and tracked daily abandonment rates, quality metrics, and call analysis reports using AVAYA CMS software to enhance productivity
- Led recruitment and hiring efforts to fill open positions (quarterly, annually?) ensuring alignment with company performance standards and culture
- Prepared and presented 20+ monthly staff performance appraisals for review with senior management, providing insights into career development and training needs
- Developed 'Test Your Knowledge' step by step guide daily and implemented customer service strategies that increased customer satisfaction by 20%
- Led onboarding efforts for 30+ new employees highlighting company policies, procedures, compliance guidelines, and fostering a knowledgeable and compliant workforce
- Designed and maintained training materials, including courses and handouts, to support ongoing staff development and knowledge retention
- Conducted 20 + customer service monthly audits of claims call to ensure accurate information delivery and adherence to policy compliance, enhancing service reliability
Claims Resolutions Specialist
Affinity Health Plan
Bronx, NY
01.2010 - 12.2013
- Reviewed and adjudicated over 60+ daily claims to ensure compliance met with the department turnaround time
- Evaluated medical claims for potential fraud, fee schedules, provider contracts recovery, medical bill coding rules, and state regulations as per CMS/Medicare guidelines
- Issued prompt refunds to members/providers for account discrepancies, ensuring satisfaction
- Executed payment transactions accurately and promptly delivered Explanation of Benefits (EOBs) to members and providers
- Assessed medical claims for potential fraud and compliance with fee schedules, provider contracts, medical coding rules, and state regulations per CMS/Medicare guidelines
- Prepared write-off documentation for uncollectible accounts, securing management approval
- Verified transactions using JP Morgan services for cleared electronic and paper checks
Education
Bachelor of Arts - Psychology
The College of New Rochelle
Bronx, NYAssociate of Applied Science - Computer Science
Monroe College
Bronx, NYSkills
- Team Leadership
- CPT Code Proficiency
- Live Chat Assistance
- Employee Performance Review
- Quality Evaluation
- Strategic Development
- Insurance Policy Expertise
- Data Analysis
- Performance Metric Oversight
- Facets knowledgeable
- Quality Assurance Oversight
- Employee Scheduling
- Expertise in MS Office Applications
- Google Workspace Proficiency
- Kronos Workforce Management
- E-Paces Proficiency
- CVS Caremark Experience
- Emdeon ABF Expertise
- Adobe Suite Proficiency
- Experienced with Availity Platform
- Experience with Avaya CMS
- Automated Call Distribution
- Documentation Analysis
- Effective Team Collaboration
- Dispute Resolution
- Efficient Documentation Handling
- Claims Evaluation
- Conflict Resolution
- Claims Processing
- Software Proficiency
- Critical Thinking Expertise
Certification
ICD 10 & 11 Medical Coding & Billing Certification, Information Technology University (ITU), Remote
Professional Highlights
- Implemented bilingual web seminar trainings to demonstrate to Spanish speaking members how to utilize the organizational web portal, which inadvertently prevented disenrollment rate by 33%.
- Reduced average handling time by 15% through implementation of active group chat for employees to reference while on calls with members and providers.
- Recovered thousands of dollars by identifying and resolving system issues that led to claim denials and by correcting and reprocessing incorrectly handled claims, achieving a 20% correction rate.
- Enhanced team performance by 10% by creating 'Test Your Knowledge' user manual to ensure team was accurately answering calls and processing claims.
- Received a 99% monthly customer satisfaction rating through telephone, chat, and email communications.
Languages
Spanish
Full Professional
Timeline
Claims Agent
Ascension Smart Health Plan
10.2021 - Current
Customer Service Supervisor
Affinity Health Plan
12.2013 - 11.2018
Claims Resolutions Specialist
Affinity Health Plan
01.2010 - 12.2013
Bachelor of Arts - Psychology
The College of New Rochelle
Associate of Applied Science - Computer Science
Monroe College
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