RESEARCH AND INSURANCE PROFESSIONAL
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Seasoned Licensed Property and Casualty/Life and Health Insurance Agent and Business Graduate.
Trained in Case Management Escalations for appeals and grievances for CMS.gov as well as handling agent and member complaints.
Adept at applying set procedures, following guidelines to accurately resolve issues. Working within set regulatory and compliance requirements.
Experienced Quality Assurance Reviewer, trained for leadership roles in a call center environment.
Skilled and experienced in training and development of peers in service and sales roles.
Excellent work ethic, proficient in MS suite programs, Google+, Verint, Facets, Lotus Notes, Reflections and various other technologies. Eager to learn and develop new skills and apply existing business knowledge to a new career.
ENROLLMENT COORDINATOR - ACA Appeals and Grievance
ASCENSION/ABS - USHL – REMOTE | March 2023 – January 2026
Regulatory & Product Compliance
Managed CMS compliance by reviewing and resolving member complaints, appeals, and grievances.
Administered FFM member data using SEED and HICS platforms in strict compliance with CMS and state rules.
Maintained ACA mailbox to manage and process 834 EDI maintenance files.
Calibrated plan rates and codes with CMS systems to ensure accurate account alignment.
Met strict compliance deadlines by documenting case findings and resolving open FFM HICS cases.
Drafted and issued official decision letters for member appeals and resolutions.
Enforced strict HIPAA compliance across all internal and external communication channels.
Corrected member accounts for CMS dispute sheet EDI resubmission and SEED updates.
Data Quality & Systems Management
Eliminated data duplicates using advanced Excel formulas during departmental dissolution.
Managed tracking spreadsheets to monitor and record critical member account updates for CMS.
Monitored casework status systematically across company databases and spreadsheets.
Audited 1095A Tax forms to guarantee accurate compliance and regulatory reporting.
Member Issue Resolution & Support
Resolved Tier 1 & 2 marketplace cases regarding premiums, APTC, and enrollment discrepancies.
Analyzed AUD and 834 files to troubleshoot and correct marketplace application errors.
Audited billing and coding data to ensure accurate payment records and filings.
Investigated claim and call histories to resolve complex, high-priority member issues.
Partnered with cross-functional teams to restore member access to care and process refunds.
Analyzed ACA and DCHP reports to identify and mitigate systemic enrollment trends.
Team Support & Development
Coached enrollment teams on recurring operational issues to improve performance.
Launched the QA review role for Medicaid and CHIP enrollments.
Authored training curriculum and conducted refreshers for enrollment and QA teams.
BILINGUAL- MEMBER ESCALATIONS SERVICES II - ACA Appeals and Grievance
Bright HealthCare – REMOTE | May 2022 – December 2022
Registered with CMS.gov (HICS) Health Insurance Casework System; performed work on Level – 1 and Level – 2 cases from the health insurance marketplace working with ACA members.
Researched AUD, 834 files and applications received from the marketplace.
Verified member payment along with claim and call history; integrated changes/corrections on the member account.
Coordinated with State-based exchange and Federal Facilitated Marketplace (FFM) to resolve Level – 1 and Level – 2 enrollment, premium, and APTC/CSR disputes/discrepancies.
Recorded and resolved the open cases in the FFM HICS system database within strict compliance deadlines.
Collaborated with member services level 1 teams and clinical staff to solve any access to care issues.
Assisted sales department with automation issues with member applications.
Communicated with underwriting to solve member eligibility details.
Communicated with members to provide additional details/clarifications of escalations and send correspondence.
Maintained strict adherence to HIPAA privacy and security guidelines in all communications with internal departments and external customers.
Handled billing corrections/disputes, processed payments for reinstatement, refunds for cancellations and associated problems.
Managed re-enrollment and dis-enrollment appeals and updated the necessary records and systems for members; corrected enrollment and application issues and disputes.
Ensured all customer needs and problems are properly communicated and managed.
Processed updates to member records, created follow-ups; ensured down streaming accurately to all company systems.
BILINGUAL- MEMBERSHIP AND ENROLLMENT SPECIALIST I (MES)
Apex Systems, LLC (Bright HealthCare) – REMOTE/Contingent | Dec 2021 – May 2022
Delivered Level – 1 customer service support by answering ACA calls regarding enrollment, eligibility, and billing.
Worked with internal and external partners to resolve Level – 1 member issues; a facilitated collection of outstanding premiums.
Worked with state-based exchange and FFM to resolve Level – 1 enrollment eligibility, premium, and APTC/CSR disputes.
Participated in the discovery and resolution of the root cause for recurring issues.
Worked with members in the grace period and resolved billing issues to collect the outstanding premium.
Maintained strict adherence to HIPAA privacy and security guidelines in all communications with internal departments and external customers.
Created, processed, and updated tickets to resolve internal technical member issues.
BILINGUAL- LICENSED LIFE AND HEALTH INSURANCE AGENT - CONTRACTOR
Healthcare Solutions Team, LLC - REMOTE | September 2021 – December 2021
Licensed in multiple states including, TX, NM, FL, MI, and TN.
ACA Help on Demand trained
BILINGUAL- MEDICAL SERVICE SURVEYOR - REMOTE CONTRACTOR The Crossroad Group, LLC – February 2019 – September 2021
Performed random call sampling and phone interviews with the assigned Medicare and Medicaid clinic patients.
Tabulated responses and precisely typed patient comments maintaining excellent grammar and spelling; retained professional and courteous phone etiquette and adhered to set verbatim questionnaires.
Submitted weekly reports timely and accurately.
Maintained strict adherence to HIPAA privacy and security guidelines in all communications with internal departments and external customers.
BILINGUAL- MEDICAL CALL PROCESSOR
Medical Service Bureau Inc. – REMOTE/El Paso, TX | Jun 2015 – Apr 2019
Processed incoming calls from patients, doctors, and nurses; followed the set protocols for paging doctors or nurses, per on-call schedules, and redirected calls as per office guidelines, time slot, and call type.
Maintained mandatory metrics based on talk time, disconnect, availability, and hold time.
Processed clients’ temporary status updates to their accounts; resolved their issues by submitting tickets for requested process updates.
BILINGUAL- SERVICE AND SALES ASSOCIATE
Ralph Dickerson, State Farm Ins. Agent - El Paso, TX | Jan 2015 – Mar 2015
Licensed Service and Sales Agent.; administered day-to-day activities, including reviewing, verifying, and contacting customers on their accounts.
Processed underwriting requests for forms and customer responses; selection/rejection forms and discount requirement forms.
Maintained strict adherence to HIPAA privacy and security guidelines in all communications with internal departments and external customers.
Annette Sanders State Farm Agent - El Paso, TX | Oct 2014 – Jan 2015
Worked as a Licensed Sales Agent and processed the daily marketing sales quotes.
Procured new business through marketing tools using existing customer referrals, underground Elephant, leads from outside events, and telephone marketing.
Reviewed discounts available for policies in addition to up-selling multi-line discounts on Fire, Auto, or Life, safe driving program enrollment discounts, and safe auto/home discounts.
Maintained strict adherence to HIPAA privacy and security guidelines in all communications with internal departments and external customers.
VIRTUAL - QUALITY SERVICE SPECIALIST
State Farm Ins. - El Paso, TX | Apr 2012 – Dec 2013
Established quality review standards, procedures, and guidelines for a new department.
Developed relationships, shared information, and achieved team goals by creating, and presenting tips on procedure changes and refreshers for sales agents; provided bi-weekly/monthly updates and reports for leadership.
Aligned individual and team activities with enterprise goals by reviewing Sales Agents' work through call monitoring and recording tools (Verint).
Maintained partnerships across the departments by working directly with auto/fire underwriting specialists, training analysts, and bank analysts to improve and update knowledge base systems.
Experience deploying and exploring best practices, tools and new technologies
Acted as a valuable resource, provided input, and positively influenced others by traveling to and leading training classes in newly established HUB sales locations in AZ and GA.
Conducted coaching and development sessions for representatives based on inquiries, trends, and reviews.
US Census Bureau - El Paso, TX | Feb 2010 – Aug 2010
Located and identified homes on county/city maps conducted interviews of home residents and documented all information correctly.
Review other enumerators' work for comprehensiveness
Reviewed, audited, and confirmed enumerator’s work for accuracy.
BILINGUAL SALES REPRESENTATIVE | State Farm Ins. - El Paso, TX - (Oct 2006 – April 2012)
PARALEGAL/LEGAL ASSISTANT | Mounce, Green, Myers, Safi, Paxson & Galatzan PC - El Paso, TX - (Aug 2005 – July 2006)
BILINGUAL CUSTOMER SERVICE REPRESENTATIVE | State Farm Ins. - El Paso, TX - (Jan 2001 – Oct 2006)
SENIOR ASSISTANT STORE MANAGER | Circle K - Las Cruces, NM - (Jan 1999 – Oct 2000)
Bachelor of Business Administration in Finance | NMSU - Las Cruces, NM
Minor of Business in Insurance | New Mexico State University - Las Cruces, NM
Associate of Applied Science - Paralegal | DACC -NMSU - Las Cruces, NM
General Lines - Property and Casualty License (2006 – Active) Issued: 12/18/06
General Lines – Life, Accident, Health and HMO License (2015 – Active) Issued: 01/14/15
