Wildana Cruz Diaz
Cranston,RI
Summary
Dedicated and results-driven Customer Service Professional with over 10 years of experience in high-level retail, sales, and healthcare customer service, specializing in troubleshooting, issue resolution, and client advocacy. Over 9 years of experience in office environments, excelling in remote operations, CRM systems, and process improvement. Fully bilingual in English and Spanish, with a strong ability to build rapport with diverse clientele and effectively navigate complex situations. Adept at problem-solving, mentoring, and training, consistently recognized for exceeding expectations in performance metrics and contributing to team success. Highly skilled in customer retention strategies, claims processing, policy compliance, quality assurance, and CRM systems. Proven ability to identify operational inefficiencies and implement strategic improvements that enhance customer satisfaction and business outcomes.
Overview
24
24
years of professional experience
Work History
Member Services
Molina Healthcare
11.2022 - Current
- Handle complex customer inquiries and claims disputes via phone, ensuring timely resolutions
- Assist members and providers in website registration, account navigation, and policy clarification
- Process high-volume written correspondence, ensuring 100% compliance with follow-up protocols
- Maintain performance & quality standards exceeding established call center metrics
- Identify and correct billing inaccuracies in claim payments, escalating issues for adjustment
- Conduct proactive outreach to new members, educating them about services and healthcare benefits
- Respond to incoming calls efficiently, addressing patient needs, medication concerns, and billing inquiries
- Maintain accurate patient census data, ensuring proper scheduling of first doctor’s appointments
- Provide additional patient support, including calling doctor’s offices to request the status of Prior Authorizations and scheduling their first doctor’s appointment
- Provide support with community support resources
Customer Support
Randstad (Wolters Kluwer)
11.2021 - 08.2022
- Identify and document resolution to reoccurring inquiries
- Cross-train on other products and systems
- Participate in projects and as well as process improvement initiatives
- Provide general reports to management as requested
- Participate in product testing and review as required
- Secure and keep confidential product and customer data
- Handle phone, e-mail, and chat support for moderate to complex system or content issues; identify, resolve, and escalate issues when necessary; record these interactions in our customer relationship database
Ambetter by Sunshine Health member services
Sunshine Health
06.2018 - 03.2020
- Respond to telephone or written correspondence inquiries from members and providers within established timeframes utilizing current reference materials and available resources
- Assist members and providers regarding website registration and navigation
- Document all activities for quality and metrics reporting through the Customer Relationship Management (CRM) application
- Process written customer correspondence and provide the appropriate level of timely follow-up
- Maintain performance and quality standards based on established call center metrics, including turn-around times
- Research and identify any processing inaccuracies in claim payments and route them to the appropriate site operations team for claim adjustment
- Reach out to all new patients and introduce them to services and products via telephone
- Respond to incoming calls and answer any related questions
- Maintain patient census and reach out to patients before they need their medications
- Ascertain from the patient all their supply needs and review medication inventory
- Offer any additional support or assistance, such as consultations with pharmacists and classes
- Maintain statements and inform patients of co-pays and past-due amounts
- Process payments in the form of credit, debit card, or bank account transactions
- Schedule delivery of medication after all patient needs are addressed
- Proficient in two lines of business or more (e.g., Medicaid, Marketplace, Medicare)
Hotels Corp Agent (Sales representative)
Westgate Resort
02.2016 - 01.2018
- Responsible for responding to incoming phone calls
- Answer questions regarding resort amenities, unit descriptions, location and travel directions, and reservation confirmations
- Qualify customers and hook guests on a tour presentation
- Book reservations
- Familiarity and efficiency with computer systems, knowledge of seasonal rates, and awareness of black-out dates
- Confirm/Cancel reservations
- Cross-sell Sales skill with the ability to determine needs
- Problem resolution Ability to solve problems without hesitation
- Called owners to obtain referrals, such as friends and family who have the potential to purchase and become new owners
- Mail out marketing materials to assist owners with their referrals; Update owners on new marketing materials
- Assisted owners with the Owner Referral Corporate Program/Owner Events/Westgatespace.com
- Create and modify documents using Microsoft Office programs such as Word and Excel
- Managed general clerical duties such as answering the telephone, filing, faxing, scanning, and data entry
- Assisted owners in building up their referral lists for excellent owner rewards while providing outstanding customer service
- Compliance with all CFI policies and departmental procedures to generate prospect leads into the database
Sales Manager
Aaron’s Sales & Lease
12.2011 - 06.2014
- Ranked in the top 10% of sales associates in the Northeastern district, Manage the overall sales functions of the store inside and outside sales
- Drive sales by building authentic customer relationships, Set and achieve weekly and monthly sales goals
- Generate new business by developing and implementing community marketing strategies
- Review and close lease agreements as directed by the store manager; assist store manager with inventory
- Assist store manager with product ordering, including planning for future sales, events, and stock balancing
- Ensure the showroom floor is merchandised, Maintain the store’s warehouse in a neat and orderly manner, Monitor and ensure efficient operation of the cleaning station in the warehouse, personally support every customer to Own it
- Counsel customers to gain timely renewal payments, contact customers directly who have not made payments to get the customer
- Drive Sales through building authentic relationships with customers
- Assist with store sales through store marketing
- Input customer information into the store computer for new lease agreements
- Update customer information and account status in the store’s computer system
Administrative Assistant
Bureau of Regulation and Certification of Health P
01.2001 - 10.2009
- Answered multi-line phone system, routing calls, delivering messages to staff and greeting visitors.
- Maintained inventory of office supplies and placed orders.
- Managed phone and email correspondence and handled incoming and outgoing mail and faxes.
- Completed forms, reports, logs, and records to quickly handle all documentation for human resources.
- Met and guided complainants, attended to phone calls, assisted legal counsel in ordering investigations, recorded the proceedings at the hearings, prepared minutes of the time
- Archived all scanned data into relevant folders
- Prepared formal complaints, preparation of motions and stipulations
- Prepared resolutions, preparation of draft laws and the recommendations by the legal counsel (attorney)
- Coordinated meetings with members of the lawyers of the different boards, transcribed views
- Do the research to see if people are in the professional health field with an expired license.
- Refer cases to various examination boards.
Education
BBA - Project Management
NUC University Online
Remote08-2026
High School - undefined
Escuela del Albergue Olímpico
Salinas, PR01.1999
Skills
- Microsoft Word
- Microsoft Excel
- PowerPoint
- Outlook
- Bilingual
- Multi-Tasking
- Good organizational abilities
- Fast learner
- Good problem-solving
- Ability to work on own initiative
- Management skills
- Customer service
- Troubleshooting
- Issue resolution
- Member services coordination
- Member services
Accomplishments
· Achieved a Quality Score of 97.36% and an NBA score of 94.98%, surpassing company targets
· Exceeded expectations in Adherence (90% with UPTO < 40 hours) and Compliance.
· Acted as a Subject Matter Expert (SME), assisting with GPT Pilot Testing and mentoring new hires
· Completed more than 15 additional LinkedIn training courses to enhance industry and management knowledge
· Supported TX/KWA Lead Team Initiatives, including IVR/SMS chat interactions.
· Demonstrated strong leadership and integrity, reinforcing company policies and best practices
Achievements Contributions
- Achieved a Quality Score of 97.36% and an NBA score of 94.98%, surpassing company targets.
- Exceeded expectations in Adherence (90% with UPTO < 40 hours) and Compliance.
- Acted as a Subject Matter Expert (SME), assisting with GPT Pilot Testing and mentoring new hires.
- Completed more than 15 additional LinkedIn training courses to enhance industry and management knowledge.
- Supported TX/KWA Lead Team Initiatives, including IVR/SMS chat interactions.
- Demonstrated strong leadership and integrity, reinforcing company policies and best practices.
Key Achievements Strengths
- Quality Score of 97.36% & NBA Score of 94.98%, surpassing company expectations.
- Recognized Subject Matter Expert (SME) mentoring and training new hires.
- 10+ LinkedIn Learning Certifications completed to enhance industry knowledge.
- Lead Team Contributions to GPT Pilot Testing and IVR/SMS chat initiatives.
- Highly proficient in CRM systems, policy compliance, and issue resolution.
- Currently completing a bachelor’s in project management, expected graduation: 08/26.
Languages
English
Professional Working
Spanish
Full Professional
Timeline
Member Services
Molina Healthcare
11.2022 - Current
Customer Support
Randstad (Wolters Kluwer)
11.2021 - 08.2022
Ambetter by Sunshine Health member services
Sunshine Health
06.2018 - 03.2020
Hotels Corp Agent (Sales representative)
Westgate Resort
02.2016 - 01.2018
Sales Manager
Aaron’s Sales & Lease
12.2011 - 06.2014
Administrative Assistant
Bureau of Regulation and Certification of Health P
01.2001 - 10.2009
High School - undefined
Escuela del Albergue Olímpico
BBA - Project Management
NUC University Online
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