TONI JONES
Fairburn,GA
Summary
Analytical contributor with a strong focus on enhancing customer experiences through data-driven insights. Expertise in managing multiple priorities while maintaining accuracy in claims resolution and customer inquiries. A proactive contributor skilled in identifying root causes and streamlining processes to achieve compliance and satisfaction goals.
Overview
9
9
years of professional experience
Work History
Data and Analytics Consultant
CVS HEALTH CORPORATION
Remote
01.2026 - Current
- Review and analyze claim submissions and supporting documentation to validate eligibility and determine whether claims were adjudicated in accordance with Federal Surprise Billing requirements.
- Analyze claim data and apply established criteria to accurately identify and resolve open negotiation requests.
- Apply strong analytical, organizational, and problem-solving skills to manage multiple claims and priorities while maintaining accuracy and attention to detail.
- Communicate professionally with healthcare providers and billing agencies via email regarding open negotiation requests, claim status, eligibility, and required documentation.
- Maintain organized records and ensure timely follow-up on outstanding claim-related inquiries and requests.
Resolutions Agent
CVS HEALTH CORPORATION
Remote
06.2024 - 01.2026
- Investigated and resolved over 500 member complaints via the state Departments of Insurance (DOI), Better Business Bureau (BBB), social media channels, Aetna's Executive Office, and Broker Services Department.
- Collaborated with compliance, legal, and leadership teams to identify root causes and streamline processes, reducing repeat escalations.
- Assisted frontline representatives with real-time escalations and provided accurate policy guidance to enhance call center operations.
- Analyzed complaint data to identify trends and recommend actionable process improvements that improved customer satisfaction and compliance outcomes.
- Investigated unauthorized enrollment (UAE) cases to ensure compliance and mitigate potential risks.
Mentor/Escalation Specialist
CVS HEALTH CORPORATION
Remote
12.2023 - 06.2024
- Consistently achieved top-tier performance metrics for quality, call handling, and customer satisfaction.
- Delivered empathetic and professional communication to de-escalate challenging situations, and ensure positive member experiences.
- Resolved complex member concerns regarding benefits, claims, and service issues, ensuring swift resolutions and improved member satisfaction.
- Collaborated with leadership and quality teams to analyze trends and implement process improvements, resulting in enhanced service delivery.
- Mentored new and existing Health Concierge representatives by providing coaching and real-time support, leading to improved performance and service quality.
Health Concierge
CVS HEALTH CORPORATION
Remote
12.2022 - 12.2023
- Coordinated care for members by collaborating with providers, the pre-certification department, and the pharmacy department.
- Consistently met or exceeded key performance metrics, including first-call resolution, call quality, and customer satisfaction scores.
- Addressed member inquiries on claims, billing, eligibility, and provider networks, ensuring accuracy and professionalism.
- Maintained HIPAA compliance, and handled sensitive health information with confidentiality and care.
- Documented interactions and followed up on open issues using Salesforce.
Customer Sales and Service Expert
The Home Depot Inc
Remote
12.2020 - 12.2022
- Exceeded monthly sales goals by promoting Home Depot's online deals, services, and Pro benefits.
- Assisted customers via chat and text, delivering quick and accurate solutions to product inquiries, order issues, and return requests, enhancing overall customer experience.
- Maintained high customer satisfaction rating through friendly, professional, and solution-focused service, fostering customer loyalty.
- Collaborated with fulfillment teams to ensure timely delivery and installation of products, resolving issues efficiently to support customer needs.
- Communicated with vendors regarding inventory and special orders.
Customer Support Specialist
Elevation Connect
Remote
12.2017 - 12.2020
- Handled high-volume inbound calls from guests to address reservations, check-ins, and property details and enhancing guest satisfaction.
- Assisted guests with booking changes, cancellations, and refund requests, while maintaining accuracy and empathy.
- Coordinated with property owners, cleaners, and maintenance staff to resolve guest concerns promptly, improving overall guest experience.
- Documented case notes and follow-ups using CRM tools to maintain service continuity and accountability, while ensuring thorough support.
Education
High School Diploma -
Sandy Creek
Tyrone, GA05-2009
Skills
- CRM platforms
- Data entry
- Microsoft Excel
- Technical support
- Quality assurance
- Problem solving
- Critical thinking
- Attention to detail
- Performance metrics
- Multitasking and organization
- Escalation resolution
- Interpersonal skills
Timeline
Data and Analytics Consultant
CVS HEALTH CORPORATION
01.2026 - Current
Resolutions Agent
CVS HEALTH CORPORATION
06.2024 - 01.2026
Mentor/Escalation Specialist
CVS HEALTH CORPORATION
12.2023 - 06.2024
Health Concierge
CVS HEALTH CORPORATION
12.2022 - 12.2023
Customer Sales and Service Expert
The Home Depot Inc
12.2020 - 12.2022
Customer Support Specialist
Elevation Connect
12.2017 - 12.2020
High School Diploma -
Sandy Creek