Leslie Toro
Valrico,FL
Summary
Proactive, customer-oriented health insurance professional with over 11 years of experience in reputable health insurance organization. Received acknowledgement of exceptional customer service for delivering outstanding service and consistently surpassing my quotas and maintaining customer confidence and satisfaction. Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.
Overview
11
11
years of professional experience
Work History
SENIOR PROVIDER INFORMATION MANAGEMENT REP
Highmark Inc.
01.2020 - 01.2023
- Delivered exemplary leadership in a multifaceted position in support of organizational objectives
- Conducted cost savings audit reviews, assessed supplier management, and monitored contract compliance
- Oversaw risk management, introduced technological upgrades, and directed policy and procedure implementation
- Promoted to the position after demonstrating proficiency for leadership and accountability
- Ensured compliance with National Committee for Quality Assurance, CMS, DOG regulations, BCBS, and internal and private audits
- Managed all phases of contracts including generation, signature, and execution
- Assisted co-workers with remaining on task by correcting data inputs in the CPR with precision
- Leveraged communication skills and presented information to colleagues utilized for future decision making
- Analyzed various aspects of work and determined if audits were required
- Reviewed and executed updates for a PIM Representative Report with over 500 lines of demographic changes; subsequently completed SharePoint document with productivity percentages and returned to representative
- Assessed the workflow for each trainee and submitted a SharePoint response to complete updates within 3-5 days; credited for producing 150+ items per day
- Exceeded expectations by maintaining a workflow inventory of 6,000+ and executing 2,000+ reviews monthly
- Utilized knowledge of BlueBranded plans (Highmark Inc.) as well as affiliates and subsidiaries when executing daily job requirements.
PROVIDER INFORMATION MANAGEMENT REPRESENTATIVE II
Highmark Inc.
01.2016 - 01.2020
- Offered exceptional support maintaining provider accounts, processing new practitioner requests, and handling office requests to join Highmark networks
- Completed requirements associated with provider demographic information, credentialing, and compliance
- Identified and resolved issues with file set-up, provider affiliations, reporting, and data inputs/outputs
- Oversaw interaction with providers, associated offices, billings agents, representatives, and management
- Maintained expansive knowledge regarding policies and procedures and informed providers accordingly.
PROVIDER CUSTOMER SERVICE LIAISON
Highmark Inc.
01.2012 - 01.2016
- Received inquiries from individual members, groups, providers, and brokers in a high volume client service center
- Prepared and remitted faxes pertaining to claims for providers or members
- Processed customer complaints and restored satisfaction through proactive solutions
- Additionally, ensured all responses met quality standards
- Maintained expansive knowledge regarding Pennsylvania, West Virginia, Delaware, and Medicare Advantage lines of business; additionally, used these insights for training other team members
- Selected for the SharePoint Project team via Provider Relations due to advanced acumen for process execution
- Completed detailed research prior to reaching a resolution; often engaged Provider Relations team and BOA team for resolving complex claims adjustments
- Mentored trainees transitioning out of Customer Service Training Class and instilled best practices
- Assisted with benefit coding by analyzing business requests and assigning proper designations
- Aided new benefit applications for medical or dental policy coding
- Demonstrated the ability to execute in a self-directed manner or lead teams to success.
Education
BUSINESS MANAGEMENT -
12.2015
INFORMATION TECHNOLOGY/PROGRAMMING -
12.2012
Skills
- LANGUAGES
- Spanish Advanced
- Customer Support
- Paperwork Processing
- Records Management
- Account Servicing
- Stakeholder Collaboration
Additional Information
- Customer Account Management
- Customer Service
- Attention to detail
- Complex problem solver
- Claims processing/review
- Benefit explanation
- Internal projects
- Quality control
- Utilizing resources across projects
- Managing stakeholder communications
- Managed a team of provider information management specialists, ensuring accurate and up-to-date provider data.
- Developed and implemented strategies to improve provider data accuracy and streamline processes.
- Collaborated with internal stakeholders to address provider data issues and improve overall data quality.
- Successfully managed and updated provider information databases for a large healthcare organization.
- Assisted in training new team members on data entry and information management processes.
- Collaborated with cross-functional teams to resolve provider information discrepancies and ensure accuracy.
- Developed strong relationships with healthcare providers to ensure excellent customer service experience.
- Maintained accurate records of customer interactions and resolved issues promptly and efficiently.
- Provided assistance to providers with insurance claims and billing inquiries.
Timeline
SENIOR PROVIDER INFORMATION MANAGEMENT REP - Highmark Inc.
01.2020 - 01.2023
PROVIDER INFORMATION MANAGEMENT REPRESENTATIVE II - Highmark Inc.
01.2016 - 01.2020
PROVIDER CUSTOMER SERVICE LIAISON - Highmark Inc.
01.2012 - 01.2016
Grand Canyon University - BUSINESS MANAGEMENT,
University of Phoenix - INFORMATION TECHNOLOGY/PROGRAMMING,