Kiana Diaz
Pittsburgh,PA
Summary
Driven professional with extensive experience in customer service and appeals coordination, notably at Brighton Health Plan Solutions. Excelled in process optimization and grievance handling, enhancing decision-making accuracy by conducting detailed audits. Demonstrates strong analytical skills and a courteous demeanor, achieving significant improvements in appeals procedures and customer satisfaction.
Overview
9
9
years of professional experience
Work History
Appeals Coordinator
Brighton Health Plan Solutions
02.2024 - 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.
- Developed appeals functions, policies and procedures and documentation.
- Conducted detailed audits on case files, ensuring accuracy and completeness of information for better decisionmaking.
- Ensured confidentiality of sensitive information by following strict security protocols throughout the appeals process.
- Supported management with data analysis and reporting, informing key decisions related to resource allocation and process improvements.
Senior Appeals Analyst
Optum
08.2022 - 02.2024
- Reviewed, analyzed and processed non-complex grievances and appeals.
- Collaborated with interdisciplinary teams to ensure accurate claims adjudication, reducing errors and inconsistencies in the review process.
- Analyzed and rendered determinations on assigned non-complex grievance and appeal issues.
- Facilitated cross-departmental collaboration by working closely with clinical staff and legal personnel during case reviews.
Customer Service Representative Agent
MCS
09.2019 - 08.2022
- Greeting customers in a friendly, professional manner
- Resolving product or service problems by clarifying the customer's complaint, selecting and explaining the best solution to solve the problem, expediting correction or adjustment, and following up to ensure resolution
- Serves customers by providing product and service information and assisting client in any health insurance enquiries
- Furnishing members and health care practitioners with details regarding members' benefits
- Answering telephonic and e-mail inquiries in a timely manner.
Customer Service
G.M.D. Air lines Services at SJU Airport
01.2016 - 09.2019
- Control and dispatch of wheelchairs
- Asked probing questions to determine service needs and accurately input information into electronic systems.
Passenger Service Agent/ Gate Agent
AVIANCA Air Lines
01.2016 - 09.2019
- Passenger services agent duties including issue boarding passes, check passports, drop luggage, assist passenger in baggage claim and support passenger on boarding the aircraft
- Customer service
- Protected passengers' baggage from loss, theft and damage through proper handling and oversight
- Greeted passengers and provided boarding instructions
- Managed gate, ramp and cabin services for each flight
- Assembled and issued required documentation, such as tickets, travel insurance policies and itineraries.
Sales Associate
Bostonian Clark Outlet
01.2015 - 01.2016
- Arranged new merchandise with signage and appealing displays to encourage customer sales and move overstock items
- Maintained knowledge of current promotions, exchange guidelines, payment policies and security practices
- Assisted customers by finding needed items and checking inventory for items at other locations
- Sold various products by explaining unique features and educating customers on proper application
- Built and maintained effective relationships with peers and upper management to drive team success toward common sales, service and operational goals
- Provided every customer with comprehensive assistance upon entering store through merchandise selection and completion of purchases.
Education
B.A - Criminal Justice
National University
01.2021
Skills
- Customer service
- Call center experience
- Problem-solving abilities
- Process optimization
- Courteous demeanor
- MCS Regulations knowledge
- Data entry proficiency
- Policy Interpretation
- Organizational abilities
- Strong analytical skills
- Documentation expertise
- Grievance handling
References
References will be provided upon request
Languages
Spanish
Native or Bilingual
English
Native or Bilingual
Timeline
Appeals Coordinator
Brighton Health Plan Solutions
02.2024 - Current
Senior Appeals Analyst
Optum
08.2022 - 02.2024
Customer Service Representative Agent
MCS
09.2019 - 08.2022
Customer Service
G.M.D. Air lines Services at SJU Airport
01.2016 - 09.2019
Passenger Service Agent/ Gate Agent
AVIANCA Air Lines
01.2016 - 09.2019
Sales Associate
Bostonian Clark Outlet
01.2015 - 01.2016
B.A - Criminal Justice
National University