Jessica Guzmán
San Antonio,TX
Summary
Dedicated Customer Service professional with knowledge of service delivery and proven multitasking abilities. Committed to maintaining professional relationships to increase profitability and drive business.
Overview
3
3
years of professional experience
Work History
Member Service Guide
Devoted
08.2024 - Current
- Engaging with members, utilizing technology and data to better understand their needs
- Supporting members in finding a physician or specialist that's aligned with their values and preferences
- Developing a solid understanding of our benefit offerings in order to investigate and resolve member questions
- Breaking down complex health care information so it is clear to our
members - Documenting accurate information about member needs in our system.
- Listening to members and identifying instances when higher levels of support, through our clinical partners, are needed.
- Operating in a very fast-paced, rapidly growing environment, and learning the Devoted offerings and plans, as well as abiding by HIPAA and compliance regulations.
- Working with a team that includes doctors and nurses (Clinical
Guides) so that you can seamlessly help members with service and clinical questions. - Assist other teams to support cross departmental projects when needed. We act as a team of teams.
Dispute Resolution Analyst
TMF health quality institute
07.2024 - Current
- Coordinates the delivery of re-determination files, dispute resolution documents, and reconsideration/dispute resolution decisions from and to the external entities.
- Builds a reconsideration/dispute resolution case file from evidence submitted and received and analyzes each case to ensure it meets the requirements for a valid reconsideration/ dispute resolution request as mandated by Centers for Medicare and Medicaid Services
(CMS) or other customer entities. - Analyzes and makes decisions based on medical vs. Non-medical case type, appeal/review categories, validity of appeal/dispute resolution request, and dispute resolution settlement documentation.
- Input appropriate data regarding reconsiderations, dispute resolution cases, into the applicable required systems.
- Responds to reconsideration, dispute review requests from appellants, patients, and providers.
Patient Support Center Representative
Optum
02.2024 - Current
- Utilize internal systems to resolve customer needs such as appointments, authorizations, claims, invoices, eligibility, benefits, appeals.
- Data enter PCP changes into the system and processes paperwork, as necessary.
- Recognize financial, medical, and legal risks based on data collected during customer interactions and follows appropriate procedures.
- Assist new or potential members in the choice of preferred care providers and supply general information about the medical group.
Patient Support Advocate
HealthNet Of California
11.2022 - 02.2024
- I got transitioned to a different role, within the same company.
- After concluding my role with WellCare I got transferred to Heath Net CA.
- Assisting patients on PCP updates for themselves, helping them on finding one fitting their best needs like nearest one, specialty etc.
- Calling providers office to schedule appointments for members.
- Filing Appeals and Grievances.
- Faxing POE to providers office.
- Changing medical group for member.
Healthcare Representative
WellCare
11.2021 - 02.2024
- Medicare/Medicaid Eligibility (DSNP plans)
- Inbound Calls
- Gathered information like Part A, Part B and Part D for the agent.
- Educated on what current plan the member had the start and end date for each plan they had.
- Educated the agent on what plan would the member qualify for according to their level of Medicaid, level of LIS, county she/he lived in.
- Maintained confidential patient, employee and company information in compliance with company policies and regulatory requirements.
- Gathered information, assessed and fulfilled callers needs and educated on important policies and procedures.
Education
High School -
Universidad Metropolitana de Monterrey
10-2015
Skills
- Bilingual
- Multitasking
- Customer Service
- Microsoft Word
- Excel
- Registration and Scheduling
- Call Documentation
Timeline
Member Service Guide
Devoted
08.2024 - Current
Dispute Resolution Analyst
TMF health quality institute
07.2024 - Current
Patient Support Center Representative
Optum
02.2024 - Current
Patient Support Advocate
HealthNet Of California
11.2022 - 02.2024
Healthcare Representative
WellCare
11.2021 - 02.2024
High School -
Universidad Metropolitana de Monterrey