MELANIE ADAMES
Miami
Summary
Energetic customer service professional eager to deliver positive, memorable experience to every customer. Consistently exceed expectations with strong time management and multitasking abilities. Quick learner and hard worker with natural sales talents.
Highly skilled Senior Customer Service Representative with background in fast-paced, customer-focused environments. Extensive experience resolving complex customer inquiries, improving customer satisfaction levels, and driving overall operational improvements. Strengths include strong communication skills, conflict resolution abilities, and leadership qualities that foster team synergy. Proven capacity to influence positive changes within previous roles through innovative problem-solving techniques.
Overview
15
15
years of professional experience
Work History
SR CUSTOMER SERVICE REPRESENTATIVE PBM
United Healthcare Group Optum
Miami
11.2023 - Current
- Answer all incoming PBM calls
- Explain Pharmacy plan benefits to the member
- Provide Overrides when necessary for the member
- D escalate calls when member is frustrated and solve members issue to the best of my ability
- Perform outflboujd calls to pharmacies, health plans and doctor offices
- Provide statuses on claims on a daily basis
- Evaluated team performance metrics against established standards on a regular basis.
- Resolved escalated customer complaints in a timely manner.
- Managed incoming calls from customers while providing exceptional service.
- Maintained accurate records of all employee benefit data including claims history and plan costs.
- Processed enrollment forms, changes in status forms, terminations and other benefit documents in a timely manner.
- Assisted clients in understanding their benefits and eligibility criteria by providing detailed information and support
- Assisted members with their deductibles, out of pockets and Maximum Out of pocket
- Verified members insurance coverage
- Research and respond to all claims processing inquiries and issues from various cross-functional departments within required turnaround time
- Adhere to client performance guarantees, when applicable
- Participate in meetings assigned by leadership
- Perform other duties as assigned
- Perform other duties assigned in a timely manner.
- Work through various company systems
COORDINATOR CUSTOMER RESOLUTION SPECIALIST
Ocwen Financial Corporation
Frederiksted
09.2022 - 07.2023
- Followed scripts to maintain good call control
- Determined charges for services requested, collected deposits, or payments, and arranged for billing
- Made informed decisions under stressful circumstances
- Used multiple screens all at once and various applications
- Met QA needs every month
- Answer 100-150 inbound and outbound calls
- Referred delinquent accounts to collections department as needed while adhering to legal guidelines.
- Handled customer inquiries regarding loan status or requirements via phone or email.
- Maintained accurate records of all transactions including origination fees, interest rates.
ASSOCIATE BENEFIT SPECIALIST INBOUND CONTACT REP
HUMANA CAREPLUS
Miami
09.2018 - 08.2022
- Researched assistance requested and offered accurate information to resolve issues and respond to inquiries.
- Answered inbound calls to greet and assist customers with various needs and questions.
- Resolved customer inquiries, complaints, and issues providing insightful solutions.
- Offered products and services to meet customers' needs and goals.
- Provided customer service support to answer inquiries about health plans and benefits.
- Maintained database of insured members, including demographic information and plan details.
- Resolved discrepancies between invoices and insurance claims data.
- Reviewed patient records to ensure accurate and timely billing of health insurance claims.
- Assessed eligibility of patients for health insurance coverage based on policy guidelines.
- Assisted members with thier medical insurance plans
- Assisted members with their MOOP, DEDUCTIBLES and Pharmacy plan
- Assisted members with understanding thier formulary within their plan
- Scheduled rides for member from and or to thier doctors appointments, therapy sessions, and daily life activities.
- Reloaded member cards for their groceries according to their plan
- Monitored clients' insurance coverages to ensure changing needs were met.
- Maneuvered through 15+ systems accordingly
CUSTOMER SERVICE SPECIALIST
The Marriott Hotel
Miami
06.2016 - 07.2018
- Facilitated clear communication between distribution centers, carrier companies, and customers to expertly resolve inquiries
- Handled external inquiries during peak periods to reduce wait times and maximize customer satisfaction
- Directed phone calls to shorten service time and steer conversations towards targeted solutions
- Resolved customer inquiries, complaints, and issues providing insightful solutions
- Provided solutions, recommendations and replacements with empathy and positive feedback
- Researched assistance requested and offered accurate information to resolve issues and respond to inquiries
- Answered inbound calls to greet and assist customers with various needs and questions
- Handled escalated callers to reach positive outcomes
- Addressed customer concerns and complaints and resolved issues promptly.
BILLING SPECIALIST
The Executive Insurance Services
St. Croix
04.2014 - 06.2016
- Incorporated authorized third party invoices into customer invoicing
- Resolved invoicing issues within required time frames and posted on accounts receivable reports
- Delivered and prepared statements to patients regarding out-of-pocket expenses
- Analyzed monthly account receivable reports to facilitate timely filing, third-party payments and consistent cash flow
- Secured and maintained medical documentation to support claims or appeals
- Demonstrated continuous effort to improve operations, decrease processing times and streamline work processes
- Collected and analyzed billing information to identify discrepancies or errors in billing procedures
- Engaged clients to review and verify billing requirements and formats
- Followed up to determine status of pending invoices under review by individual departments
- Supported legal staff, attorneys and billing teams as single point of contact for invoicing questions.
DATA ENTRY SPECIALIST
Clinical laboratory Inc
Christiansted
02.2010 - 06.2015
- Checked proper patient identification and labeled collection receptacles before collecting blood units and samples
- Traveled to hospital rooms to collect blood specimens and transported samples to laboratory
- Batched and verified accuracy of laboratory sample labels for outgoing delivery to reference laboratories
- Took standard precautions by using personal protective equipment
- Made photocopies and mailed records to support data collection and project completion.
- Created comprehensive Excel spreadsheets to organize large datasets.
- Transferred data from hard copy to computer files and database systems.
- Entered data by inputting alphabetic and numeric information using established procedures.
- Transferred data from hard copy formats into computer files and database systems.
Education
Bachelor of Science - BUSINESS MANAGEMENT
Western Governors University
Salt Lake City, UT05-2025
Certificate of Technical Studies - Phlebotomist Technician
St. Croix Trade School
Christiansted, VI10-2014
HIGH SCHOOL DIPLOMA -
South Bronx Job Corps Academy
Bronx, NYSkills
- Problem resolution
- Multi-line telephone operations
- Collections
- Business operations support
- Customer service
- Conflict resolution
- Data analysis
- Software proficiency
- Attention to detail
- Call center experience
- Returns and exchanges
- Credit card processing
- De-escalation techniques
- Payment processing
- CRM software
- Customer service excellence
Languages
Spanish, Native
Timeline
SR CUSTOMER SERVICE REPRESENTATIVE PBM
United Healthcare Group Optum
11.2023 - Current
COORDINATOR CUSTOMER RESOLUTION SPECIALIST
Ocwen Financial Corporation
09.2022 - 07.2023
ASSOCIATE BENEFIT SPECIALIST INBOUND CONTACT REP
HUMANA CAREPLUS
09.2018 - 08.2022
CUSTOMER SERVICE SPECIALIST
The Marriott Hotel
06.2016 - 07.2018
BILLING SPECIALIST
The Executive Insurance Services
04.2014 - 06.2016
DATA ENTRY SPECIALIST
Clinical laboratory Inc
02.2010 - 06.2015
Bachelor of Science - BUSINESS MANAGEMENT
Western Governors University
Certificate of Technical Studies - Phlebotomist Technician
St. Croix Trade School
HIGH SCHOOL DIPLOMA -
South Bronx Job Corps Academy