Sylvia Dominguez

Compliance Appeals, Third-Party-Liability Lead

HMA, LLC

05.2018 - 09.2023

Professionally handled customer inquiries courteously regarding benefits and eligibility, claim status. Quickly de-escalating customers concerns, complaints, claims issues, and major issues. Promoted to Supervisor and Trainer.
Supervised over seeing multiple customer service departments along with sharing the daily operations of the customer service department. Ran reports and analyzed data, created department shift schedules to meet the needs of the customer service department peak hours to establish minimal to zero wait times. Participated in the interview and hiring process. Generated and created training material based on current updates, processes and procedures including but not limited to introduction, closing, rebuttal scripts and reference guides. Coached, trained, and mentored team individuals identifying strength and weak areas. Maintained customer satisfaction with forward-thinking strategies focused on addressing customer needs and resolving concerns. Promoted to Lead of the Compliance Appeals department.
Intercepted incoming State Complaints corresponded with attorneys including but not limited to attorney generals ,department of insurance , better business bureau. Assisted in major complaints from the department of labor investigations by gathering and collecting data requested . Revised templates and created response letters. Thoroughly reviewed and investigated complaints conducted audits , including but not limited to CSR call notes , recorded calls, claims processing and handling, benefits and eligibility, audits. Identified and resolved issues with providing directive and communication to the necessary departments including but not limited to the finance, claims, customer service, and contracting departments. Provided requested information and complaints resolution and or provided explanation and proof in compliance insured claim processed with state complaint and federal law including but not limited to the No Surprise Act ("NSA").
Responded to Provider, Member, Attorney appeals grievances and provider negotiation request. Investigated and reviewed appeals to determine proper resolution based on plan documentation processes and procedures and in compliance with federal and states mandates. Held negotiation with providers regarding underpaid claims, verified timely requirements, obtained pricing from Fair Health data base to ensure payment accuracy. Upheld or overturned appeals, disputes, grievances. Created, draft, and finalized determination letters stamped sealed and mailed resolution letters within timely correspondence. Opened and closed high volume of appeals within the software program. Tracked and kept record of incoming appeals and attachments while maintaining an organized structure. Also became lead of Compliance Third-Party- Liability ("TPL") department.
Communicated with Attorneys via email, fax, or phone regarding Third-Party Liability pursuits. In correspondence to the attorneys request. Verified required documents are received and signed including but not limited to the letter of representation and the claimants signed release of PHI. Ran claims reports to establish a lien letter. Created current, and final lien letters. Communicated with participants to determine if injury and or accident is part of a Third-Party-Liability case or could be a potential case including but not limited to motor vehicle accidents, personal injury protection workers comp injuries, home owner protection, claims.

Claims Administrator

Adecco Staffing Agency

08.2017 - 02.2018

Processed Class Action Claims for Volkswagen emission law suit, Verified claimants eligibility requirements and class settlement per the settlement agreement. Verified required documents are received such as proof of insurance, title, registration.
Purchased VIN checks to ensure claimant is the proper person registered to the vehicle
Contacted financial institutions to obtain payoff quotes.
Evaluated claims and contacted claimants to advise of class process change and requirements.
Audited the prelim, verified claim settlement went trough all processes and procedures and met all eligibility requirements.

Claims Representative

HCM Staffing

03.2017 - 08.2017

Processed warranty claims and purchases.
Answered high volumes of calls from customers regarding the assembly of products , warranty details, purchases and returns.
Assisted customers in the selection of products. Provided marking support by upselling for special promotions.
Approved and denied warranty claims.
Maintained contact and followed up on problems that require special handling.
Reviewed images of products to determine warranty approval an denial.

Summary

Overview

Work History

Compliance Appeals, Third-Party-Liability Lead

Claims Administrator

Claims Representative

Education

High School Diploma -

Skills

Timeline

Compliance Appeals, Third-Party-Liability Lead

Claims Administrator

Claims Representative

High School Diploma -

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