Dora Sifuentes

Manage and resolve member complaint and grievance cases in compliance with Medicare and company guidelines.
Conduct thorough research using multiple internal systems and applications to investigate member concerns, identify root causes, and determine appropriate resolutions.
Communicate directly with members by phone to gather information, provide case updates, explain findings, and ensure a positive member experience.
Review case documentation, claims, enrollment information, and other relevant records to support accurate and timely case resolution.
Prioritize and manage a high-volume caseload while meeting regulatory and internal turnaround time requirements.
Ensure all member outreach, research activities, documentation, and case closures are completed within established deadlines.
Answer incoming member and provider inquiries, addressing concerns and escalating issues when necessary.
Maintain detailed and accurate records of case activity, member interactions, and resolution outcomes.
Collaborate with cross-functional departments to obtain information, resolve complex issues, and ensure compliance with Medicare regulations and quality standards.
Demonstrate strong analytical, problem-solving, and customer service skills while balancing multiple priorities in a fast-paced environment.

• Answer a high volume of inbound Customer calls. Provide professional customer service in regards to their utility account. Assist new customers in opening new accounts. Maintain professional attitude, respond to irate, difficult and challenging customers. Input information and request timely and accurately. Adhere to company policies and procedures.

• Perform all Medical Operator duties. Respond to emails. Compile after hour electronic emails and fax records, print and manually fax to offices. Handle escalated calls from patients, nurses or doctors. Complete our weekly schedule received from over 150 medical offices, hospitals, nursing homes and rehabilitation centers. Speak with all medical personnel on any changes, make changes to show correct doctor on call, note and lock account to prevent use. Other duties as assigned by the office Manager.

• Answer patient inbound after hour calls for medical offices, for medical emergency advice get necessary info to page/call their Dr. Follow up with patient within the necessary time frame to ensure their Dr. called. Answer hospital and private office calls; speak with nurses, doctors, all other medical personnel to get them in contact with their requested doctor.

• Proactively work with new customer concerns. Work with Technical Assistance, GM Dealer, and all management for timely resolution. Communication and rapport building with customers. Case management of 10-15 per week. Empowered to make decisions up to $6,000. Process compensation checks, repurchase or trade vehicles. Assigned high-risk cases.

• Assist dissatisfied customers who filed with the Better Business Bureau. Work on time sensitive NISMs’ (not in suit matter) cases, Attorney contact, Review and comply with the customer’s State Lemon Law. Handle negotiations between the customer and General Motors. Build a firm business case for compensation, repurchase or trade. Case management of up to 15 cases weekly.

• Obtain customer information, case set up. Provide product knowledge, answer a wide range of questions, resolve customer complaints, one call resolution, and escalate high priority cases. Assist with website navigation and technical assistance. Refer and transfer to appropriate departments for individual needs. Handle 30+ calls per day.

• Work escalated cases from customer service. Work with GM Service, Dealer Sales, and GM Field Manager to create an action plan for resolution. Accurate documentation of all interactions. Empowered to make decisions of up to $2,000. Handle daily 30+ cases weekly.