Summary
Overview
Work History
Education
Skills
Languages
Publications
Timeline
Generic

ELIZABETH GOMEZ

Wimauma,FL

Summary

Bilingual Seasoned Grievance and Appeals Specialist specialist with strong background in health insurance benefits. Excellent planning and problem solving abilities. Offering over 18 years of experience and a willingness to take on any challenge. Organized, driven and adaptable professional with successful history managing high caseloads in fast-paced environments. Demonstrated success in handling Medicare customer issues, including plan benefits, enrollments, appeals, and grievances. Responsible for the processing, research, and preparation of time-sensitive group insurance renewals by presenting the best plan options to maintain the book of business.

Overview

25
25
years of professional experience

Work History

GRIEVANCE AND APPEALS REPRESENTATIVE

Humana Health Plans Inc./CarePlus Health Plans
Wimauma, FL
02.2023 - Current
  • Respond to grievances and appeals, achieve timely resolutions and maintaining strict HIPAA compliance
  • Collaborate with clinical teams to resolve complex cases, improving case resolution efficiency
  • Analyze complaint trends to identify patterns and implement process improvements
  • Streamline grievance handling processes, balancing efficiency with high-quality customer support
  • Identify complaint trends and implement process improvements for non-routine concerns, enhancing overall grievance handling efficiency
  • Drive measurable improvements in case resolution by balancing efficient grievance handling with high-quality customer support
  • Meticulously manage sensitive member information, ensuring client confidentiality and upholding stringent HIPAA compliance standards
  • Analyze grievance patterns to implement targeted process improvements, enhancing overall complaint resolution efficiency and client satisfaction
  • Drive measurable improvements in case resolution by balancing efficient grievance handling with high-quality customer support.

SENIOR INBOUND CUSTOMER REPRESENTATIVE

Humana Health Plans Inc.
Riverview, FL
06.2021 - 02.2023
  • Worked in a fast-paced inbound call center environment, handling 40-50 inbound calls from members daily
  • Demonstrated experience in providing a high level of customer service and attention to detail
  • Effectively engaged with customers verbally and listened to their needs, asking probing questions to address their needs
  • Recorded details of inquiries, complaints, transactions, and interactions with each inbound call
  • Researched, and investigated unresolved customer issues providing full resolutions following department protocols and guidelines
  • Worked within quality standards with minimal supervision, using multiple applications simultaneously to access member benefits, claims, prescriptions, and prior authorizations
  • Reached out to doctors or provider offices on issues such as billing, access to medical care, prior authorizations, and more to provide full resolutions
  • Exceed departmental metrics and contribute to departmental service level performance.

BILINGUAL RETIREMENT REPRESENTATIVE

John Hancock
Riverview, FL
01.2020 - 05.2021
  • Responded to customer inquiries about plan benefits, researching claims, resolving enrollments, disenrollments, and assisting with a solutions-oriented approach to enhance customer interactions
  • Provided effective and expedited resolutions by researching complaints for a variety of customer inquiries, such as withdrawals and loans, that were time-sensitive and required expedited resolution
  • Responded to and resolved customer telephone inquiries and concerns related to 401(k) and retirement products and services, handling PHI professionally and according to corporate policy
  • Ensured effective solutions for our customers by demonstrating problem-solving and conflict-management skills
  • Resolved inquiries within standard response times and obtained information required to solve customer problems, including escalations.

ACCOUNT MANAGER

Netcare Benefits Group
Plainfield, IL
12.2005 - 01.2020
  • Managed customer service calls, concerns, complaints, health insurance claims, enrollments, and cancellations, both by phone and in person
  • Providing general administrative services, including responding to customer service inquiries regarding plan benefits, PCP changes, mailing plan materials, etc
  • Assisted with new group plan implementation by leading on-site and virtual employee open enrollment meetings
  • Responsible for preparing market research to present plan options before open enrollment using Excel, PowerPoint, and other technology to educate clients about their options and existing plans
  • Conducted research into additional ancillary product lines to provide our clients with comprehensive group benefits and cost-effective plan solutions, always promoting wellness and preventive programs for employees
  • Documented, investigated, and resolved member calls, complaints, and grievances by company policy
  • Provided excellent customer service by always answering when customers call and resolving their concerns on the first call
  • Ensure a positive customer experience and maximize service levels by meeting and exceeding daily quality and productivity expectations.

ACCOUNT MANAGER

Rose and Kiernan Inc
Pawling, NY
09.1999 - 10.2005
  • Responsible for a book of more than 150 clients generating in excess of $500,000 in annual commissions
  • Interacted daily with human resources professionals, providing day-to-day support for questions regarding benefits, plan modifications, enrollment disenrollment, carrier eligibility guidelines, serving as the point of contact for all employee inquiries
  • Processed employee enrollments online
  • Provided claims research, grievance and appeal resolution, etc
  • Conducted on-site benefit orientations for new plan implementations
  • Ensured employees were fully educated about the plans
  • In a supervisory role, designed, planned, and wrote all of the workflows for the department, streamlining procedures and improving the effectiveness of the department by eliminating an account manager position
  • Hired, managed, and completely trained two account managers, each responsible for $300,000 in commissions on their book
  • Responsible to ensure that team resources are properly allocated during peak business cycles/hours, employee holidays and/or personal illness days
  • Conducted quarterly performance evaluations of individual employees that were later used by upper management to write annual reviews for employees, enrollment, eligibility, etc
  • Contributed to the growth of the Small Group unit by bringing in 65 new businesses in 2001.

Education

Continue Education Credits AHIP -

01.2024

Betty Owen Institute -

NY
01.2001

Duchess Community College NY AA in Liberal Arts -

01.2000

Life and Health License -

Home Health Medical Terminology -

Skills

  • Time Management
  • Interpersonal skills
  • Proficient in all Microsoft applications
  • Outlook
  • Softphone
  • Rx Nova
  • Rx Connect
  • CRM
  • EMME
  • Genesys Cloud
  • CAS
  • CI
  • Mentor
  • CSIM
  • Microsoft Office
  • Insurance knowledge
  • Dispute Resolution
  • Effective Communication
  • Complaint Handling
  • Adaptability
  • Problem-Solving
  • Active Listening
  • Multitasking
  • Written Communication
  • Professionalism
  • Grievance management
  • Organizational Skills
  • Attention to Detail
  • Excellent Communication
  • Task Prioritization
  • Problem-solving aptitude
  • Adaptability and Flexibility

Languages

Proficient in the Spanish Language

Publications

The Little White Pigeon (Children’s book) 2009

Timeline

GRIEVANCE AND APPEALS REPRESENTATIVE

Humana Health Plans Inc./CarePlus Health Plans
02.2023 - Current

SENIOR INBOUND CUSTOMER REPRESENTATIVE

Humana Health Plans Inc.
06.2021 - 02.2023

BILINGUAL RETIREMENT REPRESENTATIVE

John Hancock
01.2020 - 05.2021

ACCOUNT MANAGER

Netcare Benefits Group
12.2005 - 01.2020

ACCOUNT MANAGER

Rose and Kiernan Inc
09.1999 - 10.2005

Continue Education Credits AHIP -

Betty Owen Institute -

Duchess Community College NY AA in Liberal Arts -

Life and Health License -

Home Health Medical Terminology -

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ELIZABETH GOMEZ