Jalimar Rivera
Orlando
Summary
Adept at navigating complex insurance regulations and fostering stakeholder relationships, I significantly enhanced appeal resolution rates and customer satisfaction at Centene Corporation. My expertise in policy interpretation, coupled with exceptional problem-solving skills, led to streamlined processes and a reduction in appeals backlog, showcasing my ability to deliver results in high-pressure environments.
Overview
20
20
years of professional experience
Work History
Grievance Appeals Coordinator
Centene Corporation
02.2022 - Current
- Acted as a departmental resource on appeals matters.
- Created, composed and maintained appeal response templates.
- Coordinated with senior specialist to compose appeal responses.
- Responded to attorney inquiries and litigation notices.
- Ensured confidentiality of sensitive information by following strict security protocols throughout the appeals process.
- Collaborated with cross-functional teams, resulting in improved communication and quicker resolutions.
- Maintained comprehensive knowledge of regulatory guidelines to ensure compliance within the appeals department.
- Streamlined appeals process for increased efficiency through consistent tracking and monitoring of cases.
- Enhanced appeal resolution rates by thoroughly reviewing and analyzing case documentation.
- Organized and managed appeals caseloads, prioritizing high-priority cases for timely resolution.
- Provided exceptional customer service by promptly responding to inquiries from appellants and other stakeholders.
- Developed strategic action plans to address identified issues, leading to a reduction in appeals backlog.
- Provided support during peak periods by assisting other departments with workload overflow; demonstrating adaptability.
- Developed strong working relationships with internal and external stakeholders, fostering a collaborative environment for efficient resolution of appeals.
- Monitored changes in regulations or policies, updating internal procedures accordingly to maintain compliance.
- Coordinated with medical professionals and subject matter experts for case reviews, obtaining necessary clarification for accurate decisionmaking.
- Contributed to a positive work environment by sharing best practices among colleagues; improving overall team performance.
- Assisted in the development of training materials, contributing to the improvement of team performance and expertise.
Customer Service Intake Representative
Humana Healthcare
01.2005 - 02.2014
- Contributed to departmental goals by consistently meeting or exceeding individual performance targets.
- Managed high call volume effectively, maintaining professionalism under pressure.
- Adapted communication style to accommodate diverse clientele, resulting in increased satisfaction ratings from customers with different backgrounds and needs.
- Identified opportunities for upselling products or services based on customers'' needs, contributing positively to company revenue growth while enhancing overall value provided to clients.
- Developed strong product knowledge to provide relevant information and recommendations to customers.
- Enhanced customer satisfaction by efficiently handling inbound calls and addressing inquiries.
- Worked closely with other departments to ensure timely resolution of complex issues affecting customers'' experiences.
- Demonstrated flexibility in working various shifts, accommodating the needs of a 24/7 customer support operation and ensuring optimal coverage during peak times.
- Recognized as a top performer within the team due to consistent high-quality customer interactions and positive feedback received from clients.
- Provided empathetic support to customers in distress, fostering trust and loyalty.
- Improved first-call resolution rates through effective problem-solving skills and comprehensive product knowledge.
- Assisted in training new hires, sharing best practices and industry insights for their success.
- Participated in ongoing professional development initiatives aimed at refining customer service skills and staying current with industry trends.
- Provided constructive feedback during team meetings regarding potential improvements that could be implemented within the department.
- Utilized CRM software proficiently, enabling efficient data entry and retrieval during customer interactions.
- Maintained accurate records of customer interactions, ensuring seamless communication across departments.
- Streamlined the intake process for improved efficiency, reducing call wait times.
- Collaborated with team members to identify areas for process improvement, contributing to a better customer experience.
- Resolved customer complaints by actively listening and offering timely solutions.
- Maintained up-to-date knowledge of product and service changes.
- Educated customers about billing, payment processing and support policies and procedures.
- Provided excellent customer care by responding to requests, assisting with product selection and handling ordering functions.
- Bolstered customer retention by creating and offering unique discount options and inspiring interest in new product lines.
Education
Associates - Bible Science
Charis Bible College
Lake Mary, FLHigh School Degree -
John Adams High School
Miami, FL05.2005
Skills
- Data entry proficiency
- Policy interpretation
- Insurance regulations
- Confidentiality
- HIPAA compliance
- Effective communication
- Strong analytical skills
- Medical terminology
- Documentation expertise
- Medical coding
- Insurance policies
- Teamwork
- Teamwork and collaboration
- Problem-solving
- Time management
- Multitasking skills
- Attention to detail
- Listening skills
- Problem-solving abilities
- Multitasking
- Multitasking Abilities
- Reliability
- Excellent communication
- Critical thinking
- Organizational skills
- Team collaboration
- Active listening
- Adaptability and flexibility
- Decision-making
- Relationship building
- Team building
- Task prioritization
- Self motivation
- Interpersonal skills
- Analytical thinking
- Conflict resolution
Timeline
Grievance Appeals Coordinator
Centene Corporation
02.2022 - Current
Customer Service Intake Representative
Humana Healthcare
01.2005 - 02.2014
Associates - Bible Science
Charis Bible College
High School Degree -
John Adams High School