Midiam E Rivera Tirado
Caguas,PR
Summary
Dedicated Appeals Representative with 4 years of experience, recognized for consistently achieving productivity goals while maintaining perfect quality scores. Named OGA Top Performer in 2024 as a C&S Provider Appeals Representative and within my department. Highly analytical in reviewing case data, detail-oriented, and adept at prioritizing tasks efficiently. An adaptable professional with strong communication skills, excelling in both independent work and collaborative team settings. Seeking a new opportunity as a SOX Audit Coordinator to leverage my expertise and contribute to organizational success.
Overview
21
21
years of professional experience
Work History
Appeals & Grievances Representative
Optum
12.2021 - Current
- Thoroughly reviewed and analyzed appeal documentation in accordance with internal policies and external regulatory requirements.
- Consistently met daily performance goals set by management team members.
- Maintained updated knowledge through continuing education and advanced training.
- Utilized various software and tools to streamline processes and optimize performance.
- Managed time effectively to ensure tasks were completed on schedule and deadlines were met.
Provider Inquiry Representative
Optum
11.2020 - 12.2021
- Provide support to address the needs of providers, taking care to thoroughly understand the type of assistance required, and identifying specific issues while documenting required information in computer systems.
- Research complex issues across multiple databases, resolve provider issues, and/or partner with others to resolve escalated issues.
- Assisted co-workers during busy periods or whenever needed in order to provide excellent customer service.
- Handled communications via phone, fax, and email to address diverse inquiries.
Teacher
Puerto Rico Department of Education
10.2005 - 02.2020
- Successfully managed and analyzed data related to student performance, implemented structured lesson plans, and maintained meticulous records for compliance and reporting purposes.
- Developed curriculum to enhance student achievement.
- Utilized technology-based learning tools to enhance classroom instruction.
- Identified and documented learning achievements by reporting outcomes.
- Conducted comprehensive research and data analysis to support strategic planning and informed decision-making.
- Collaborated closely with team members to achieve project objectives and meet deadlines.
Medical Records Retrieval Specialist
Advantmed
11.2015 - 06.2016
- Facilitate outbound communication with medical establishments in the US for HEDIS audit purposes.
- Retrieved medical records upon request from healthcare professionals.
- Researched the required information using available resources and applicable software.
- Processed and responded to internal requests for medical records, following established protocols.
Customer Service Representative
Cingular Wireless, AT&T
01.2005 - 12.2005
- Engaged in conversation with customers to understand needs, resolve issues and answer product questions.
- Answered customer inquiries via phone, fax, and email.
- Analyzed customer data and resolved inquiries while maintaining strict adherence to company policies and accuracy standards.
- Used approved scripts to de-escalate angry customers during telephone interactions.
Data Entry and Filing Clerk
Cooperativa Los Hermanos
12.2003 - 10.2004
- Accurately entered and maintained data in company databases, ensuring high levels of accuracy and efficiency.
- Organized and managed physical and digital filing systems for easy access and compliance with record-keeping policies.
- Performed routine office tasks such as photocopying, scanning, and handling correspondence to support daily operations.
Education
Graduate Coursework in Biligual Education. - Bilingual Education
Interamerican University
San Juan, PR06.2010
Bachelor of Arts - Music Education
University of Puerto Rico
San Juan,06.2003
Skills
- Compliance and regulation knowledge
- Data analysis
- Attention to Detail
- Policy and Procedure Adherence
- Confidentiality and ethical decision-making
- Strong communication skills in English and Spanish
- Teamwork and collaboration
- Goal-oriented mindset
- Positive attitude
Activities
- Professional musician whose main instrument is the violin.
- Have executed trips to several poor countries in Central America to provide clothes and shoes to the most in need.
- Have participated in several Triathlons and races.
- Active member of a community of faith with whom I share the mission of visiting the ill bringing joy through music.
Timeline
Appeals & Grievances Representative
Optum
12.2021 - Current
Provider Inquiry Representative
Optum
11.2020 - 12.2021
Medical Records Retrieval Specialist
Advantmed
11.2015 - 06.2016
Teacher
Puerto Rico Department of Education
10.2005 - 02.2020
Customer Service Representative
Cingular Wireless, AT&T
01.2005 - 12.2005
Data Entry and Filing Clerk
Cooperativa Los Hermanos
12.2003 - 10.2004
Graduate Coursework in Biligual Education. - Bilingual Education
Interamerican University
Bachelor of Arts - Music Education
University of Puerto Rico