Shelby De La Cruz
Visalia,CA
Summary
Senior customer service representative with proven performance in medical claims processing and customer satisfaction at Cigna. Maintain quality scores above 95% while resolving complex issues through clear communication and accurate case handling. Use Microsoft tools to streamline workflows and improve service delivery.
Overview
31
31
years of professional experience
Work History
Senior Customer Service Representative
Cigna Medical
10.2020 - Current
- Knowledgeable in TruCare/Icms
- Click to Chat trrained
- Understanding of payments and claims related to office and hospital visits and medical and dental procedures, and thoroughly explaining how customer benefits are applied to costs associated with these visits and procedures
- Icd10 trained
- Maintains a quality of over 95%
- Cross trained in Proclaim, PMHS, Facets, Pharmacy, CFunds
- Assists with site escalation in listed products
- Proficient in all Microsoft programs and adobe products
- Customer Focused – a genuine desire to help people
- Problem solver – understands issues and enjoy solving them
- Active listener, with the ability to provide confident responses
- Effective user of tools – including knowledge management tools and resources
- Able to manage real-time inquiries while keeping track of and responding to commitments to follow-up with customer inquiries
- Collaborator – enjoys working with co-workers across different functional areas
- assists with peer-to-peer coaching.
- led multiple agent refreshers regarding CAHMO and Guesting
- led a 5 week refresher for newly trained agents
- assists with live call/chat interactions to ensure quality assurance
- trained in PMHS/Proclaim, Facets, Pharmacy and Specialty accounts
Customer Service Representative
Cigna Medical
08.2018 - 10.2020
- Knowledgeable in TruCare/Icms/pmhs
- Understanding of payments and claims related to office and hospital visits and medical and dental procedures, and thoroughly explaining how customer benefits are applied to costs associated with these visits and procedures
- Maintains a quality of over 98% at all times
- Familiar system related to proclaim and pmhs
- Cross trained in proclaim and pmhs, both premium and One Guide
- Dedicated to covid-19 resource team
- Assists with site escalation in listed products
- Proficient in all Microsoft programs and adobe products
- Customer Focused – a genuine desire to help people
- Problem solver – understands issues and enjoy solving them
- Active listener, with the ability to provide confident responses
- Effective user of tools – including knowledge management tools and resources
- Able to manage real-time inquiries while keeping track of and responding to commitments to follow-up with customer inquiries
- Collaborator – enjoys working with co-workers across different functional areas
Customer Service Representative
Sunrise Medical
08.2017 - 08.2018
- Assists with personal and private account information
- Process Orders using multiple applications and systems
- Identify and solving needs of consumers and dealers
- Knowledge on wheelchair parts and schematics
Customer Service Representative
Covered California
09.2014 - 08.2017
- Assists with personal and private account information
- Defusing escalated situations
- Data entry- Manual verification work stream
- Identify and solving needs of consumers
- Knowledge on health plans and benefits that fit consumer needs
Customer Service Manager
ALORICA
01.2013 - 03.2014
- Assist customer with personal accounts
- Discuss billing issues with customer
- Coaching agents on how to properly handle irate/upset consumers
- Managed 10+ agents
- Performed one on ones with agents on a weekly basis.
- Handled escalated calls
- Processing Time Sheets
- Quality Assessments/ Call Auditing
Customer Service/Sales
RAY’S IRIS ACRES
04.1996 - 04.2013
- Cashier
- Answered customer questions.
- Educated customers on how to care for newly bought plants.
- Planted, dug sold plants and potted new plants.
- Confidently adapted to daily work environment changes in order to improve business
Customer Service Representative
ALORICA
06.2012 - 01.2013
- Assist customer with personal accounts
- Discuss billing issues with customer
- Floor Support for nesting and production
- Superstar Ranking 2+ times
- Exceeding company requirements or better for more than 4 months at a time
Marketing Associate
DIRECT BUY
07.2010 - 10.2011
- Answered customer inquiries both accurately and confidently
- Assist on customer complaints
- Utilizes phone and computer to research and process customer information
- Promote a safe work environment
- Successfully assisted customer in a timely manner
- Handle escalated customer situations confidently
Customer Relations/Customer Service
THE ISLAND WATER PARK
06.2008 - 08.2009
- Handled money during ticket sell transaction.
- Answer customer questions on park information, in person and over the phone.
- Assisted customer complaints by listening and negotiating and making good company decisions
- Assisted other representatives with customer help
Skills
- Checks complex cases and documents to make sure 100% of the work followed Quality and company standards
- Used internal healthcare systems to research info, verify data, and make sure different platforms match perfectly
- Kept audit results fair and accurate by writing down clear, fact-based reasons for every final decision
- Works with individuals to collaborate on chats/calls to ensure we are providing accurate and consistent information
- Provides quality review, service operations, customer service, claims, eligibility, benefits administration, client service and provider service
- Problem solving and Critical Thinking Skills
- The ability to understand policies and and articles to provide appropriate judgement and feedback
- Works proficiently with Microsoft Outlook, Teams, Word, Excel, and PowerPoint
- Experience with KnowledgeXchange
- Ability to manage competing priorities while maintaining accuracy and consistency
- Ability to work independently with limited supervision
- Knowledge of privacy, compliance, confidentiality, and PHI requirements
Email Addresses
ShelbyReed529@gmail.com, personal.
Shelby.delacruz@cignahealthcare.com, professional
Timeline
Senior Customer Service Representative
Cigna Medical
10.2020 - Current
Customer Service Representative
Cigna Medical
08.2018 - 10.2020
Customer Service Representative
Sunrise Medical
08.2017 - 08.2018
Customer Service Representative
Covered California
09.2014 - 08.2017
Customer Service Manager
ALORICA
01.2013 - 03.2014
Customer Service Representative
ALORICA
06.2012 - 01.2013
Marketing Associate
DIRECT BUY
07.2010 - 10.2011
Customer Relations/Customer Service
THE ISLAND WATER PARK
06.2008 - 08.2009
Customer Service/Sales
RAY’S IRIS ACRES
04.1996 - 04.2013