Sebastian Morales

· Dispatch emergency support (Police, Medical, Fire) assistance for active aging citizens

· Gather clues and cues about an emergency request, and relay message to 911 Operator to ensure safety of subscribers and Fire Responders

· Ability to maintain control, map reading abilities, knowledge of 911 dispatch procedures, excellent communication, and probing skills

· Support Customer Service and Operator Services inbound calls related to equipment troubleshooting, billing, general inquiries, as needed

· Create accurate logs of all communications for the purpose of assuring the general needs and safety of customers

· Advocate for members, triage calls, and report crisis situations to the appropriate agencies such as Adult Protective Services and Public Safety Answering Points

· Perform initial psychological and social assessments on a high volume of emergent and non-emergent contacts for assistance, which may include calls related to medical, social, and/or wellness

• Reached out to insurance carriers to obtain prior authorization for testing and procedures.
• Prepared and distributed denial letters, detailing reasons for denial and possible appeal measures.
• Fielded telephone inquiries on authorization details from plan members and medical staff.
• Researched denied claims and contacted insurance companies to resolve these issues.
• Tracked referral submission during facilitation of prior authorization issuance.
• Reviewed appeals for prior authorization requests and communicated with payers to resolve issues.
• Provided prior authorization support for physicians, healthcare providers and patients in accordance with payer guidelines.

• Reviewed provider coding information to report services and verify correctness.
• Used administrative guidelines as resource or to answer questions when processing medical claims.
• Maintained knowledge of benefits claim processing, claims principles, medical terminology, and procedures and HIPAA regulations.
• Paid or denied medical claims based upon established claims processing criteria.
• Responded to correspondence from insurance companies.
• Managed large volume of medical claims on daily basis.
• Evaluated medical claims for accuracy and completeness and researched missing data.
• Researched and resolved complex medical claims issues to support timely processing.
• Followed up on denied claims to verify timely patient payment and resolution.
• Generated reports on medical claims processing activities and results.
• Maintained strong knowledge of basic medical terminology to better understand services and procedures.

• Assisted customers in identifying issues and explained solutions to restore service and functionality.
• Collaborated with supervisors to escalate and address customer inquiries or technical issues.
• Translated complex technical issues into digestible language for non-technical users.
• Used ticketing systems to manage and process support actions and requests.
• Resolved diverse range of technical issues across multiple systems and applications for customers and end-users across various time zones.
• Documented support interactions for future reference.
• Managed high levels of call flow and responded to Apple Product technical support needs.
• Monitored systems in operation and quickly troubleshot errors.
• Researched and identified solutions to technical problems.
• Diagnosed and troubleshot hardware, software and network issues.