Pedro Diaz
Gastonia,NC
Summary
Professional with strong background in customer interactions and service solutions. Highly skilled in conflict resolution, communication, and problem-solving, ensuring customer satisfaction and loyalty. Effective team collaborator, adaptable to changing needs, and consistently focused on achieving results through efficient and empathetic service. Known for reliability and proactive approach to meeting customer and organizational goals.
Overview
11
11
years of professional experience
Work History
Provider Enrollment Analyst Specialist
PALMETTO GBA
02.2023 - 02.2024
- Company Overview: A Blue Cross Blue Shield Company
- Responsible for provider enrollment process to review, research, analyze, and process provider enrollment applications
- Maintained accurate and up-to-date provided data following industry standards and regulations
- Provided in-depth review and verification/validation of provider's data using government information databases and various organization agencies to ensure the authenticity of provider credentials including education, licensure, and insurance information
- Communicated with internal and external stakeholders to gather necessary information for enrollment and credentialing
- Collaborated with cross-function teams to ensure timely and accurate completion of employment and credential tasks
- Monitored and tracked enrollment and credential applications to ensure timely completion
- Identified and addressed any issues or discrepancies in provider enrollment and credentialing
- Prepared and maintained documents and reports related to provider enrollment and credential processes
- Provided excellent customer service to providers and internal teams regarding enrollment and credential inquiries
- Collaborated with leadership to identify areas of process improvement and implement solutions maintaining confidentiality and adherence to help regulate all aspects of the job
Patient Care Coordinator / Team Lead (Hybrid Role)
KROGER SPECIALTY PHARMACY
11.2018 - 01.2023
- Communicated with patients to obtain information required to process prescriptions, refills, access benefits and apply charges against copay cards
- Investigated and verified benefits for pharmacy and medical third-party claims for assigned cases
- Tracked, reported, and escalated service issues arising from requests for authorization, financial assistance, and other issues that delay service
- Obtained authorizations, initiated requests, tracked progress, and expedited responses from insurance carriers and other payers, and maintained contact with customers to keep them continuously informed
- Facilitated appeals process between patient, physician, and insurance company
- Composed clinical appeals letters based on the specific denial reason and patient clinical presentation and coordinated the appointment of a representative
- Educated customers and addressed their concerns as appropriate
- Communicated financial obligations and past-due balances
- Documented case activity, communications, and correspondence in the computer system to ensure completeness and accuracy of patient contact records
- Ensured that work activities were conducted in compliance with regulatory requirements and the organization-defined standards and procedures, and in a manner that provided the best available level of service and quality
- Reviewed analytics and compared to research performed identifying discrepancies or potential fraud situations
- Trained employees and created step-by-step training material to ensure proper role execution
- Initiated process improvements, implementing them to improve quality and efficiency
Patient Access and Program Coordinator / Team Lead (Hybrid Role)
EXPRESS-SCRIPTS
09.2014 - 10.2018
- Resolved escalated customer inquiries and complex questions submitted
- Liaised between departments to resolve cross-departmental customer issues
- Troubleshoot issues promptly to ensure compliance and continuous service improvements to meet contractual obligations
- Participated in cross-functional initiatives that support global quality assurance initiatives
- Analyzed, identified, and recommended process improvements
- Oversaw projects articulating assessment results to operations management
- Mentored team members to develop skill sets with proprietary- and ancillary system
- Developed complex end-to-end test scenarios for the quality analysts' and subject matter experts' improvement
- Established corrective action plan for subject matter experts' growth
- Partnered with leadership on special projects
- Performed quality checks on randomized cases and reported a quality trend to management
- Oversaw subject matter experts and managed escalated issues
Corporate Account Representative
CONVERGYS
04.2013 - 09.2014
- Identified key trends and customer needs
- Facilitated close of sales contracts by company policy
- Managed account relationships
- Mediated between Management and Associate Teams
- Managed confidential and sensitive information regarding customer's business environment
- Addressed and corrected issues with customer accounts
- Maintained a comprehensive understanding of the current business environment (i.e., strikes, layoffs, mergers, and acquisitions)
Education
BACHELOR OF SCIENCE (BS) - Health Business Administration, Psychology
UNIVERSITY OF CENTRAL FLORIDA
Orlando, FL05.2017
ASSOCIATE OF ARTS (AA) -
VALENCIA COLLEGE
Orlando, FL12.2013
Skills
- Medicare and Medicaid knowledge
- HIPAA Compliance
- Healthcare Industry Knowledge
- Provider enrollment
- Teamwork and Collaboration
- Application processing
- Audit preparation
- Customer Service
- Policy Interpretation
- Attention to detail
- Agility/Flexibility
- Problem-solving abilities
- Project Management
- Claims investigation
- Trustworthy
- Reliability
- Mentor
- Critical thinking
- Social Intelligence
- Conflict Management
- Client Engagement
- Change Management
- Due Diligence
- Interpersonal Skills
- Emotional Intelligence
- People Management
- Healthcare industry
Additional Information
Security Clearance obtained, Excellent verbal, written, and presentation skills, Proficient in Microsoft Office
Timeline
Provider Enrollment Analyst Specialist
PALMETTO GBA
02.2023 - 02.2024
Patient Care Coordinator / Team Lead (Hybrid Role)
KROGER SPECIALTY PHARMACY
11.2018 - 01.2023
Patient Access and Program Coordinator / Team Lead (Hybrid Role)
EXPRESS-SCRIPTS
09.2014 - 10.2018
Corporate Account Representative
CONVERGYS
04.2013 - 09.2014
ASSOCIATE OF ARTS (AA) -
VALENCIA COLLEGE
BACHELOR OF SCIENCE (BS) - Health Business Administration, Psychology
UNIVERSITY OF CENTRAL FLORIDA
Websites
Competencies Skills
- Agility/Flexibility
- Project Management
- Trustworthy
- Mentor
- Social Intelligence
- Conflict Management
- Client Engagement
- Change Management
- Due Diligence
- Interpersonal Skills
- Emotional Intelligence
- People Management
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