Karla Rodr

Dedicated Team Leader, Customer Service and Claims Specialist with 7+ years of experience in claims processing, healthcare support, and remote customer service environments. Proven expertise in managing medical and pharmacy claims, resolving complex customer issues, handling appeals and prior authorizations, and delivering exceptional service to members and providers. Skilled in utilizing claims management and CRM platforms to improve operational efficiency, ensure regulatory compliance, and enhance customer experience.

Recognized for strong problem-solving abilities, attention to detail, and a collaborative approach that contributes to team success, service excellence, and client satisfaction.

Team Leader - EVERISE-Humana Centerwell and CC/RSO medicare - Remote, TX

(2023-07 - 2025-07)

• Facilitated training sessions and knowledge-sharing activities.
• Mentored team members to support career growth and development.
• Created training materials and standard operating procedures.
• Ensured employees remained compliant with company policies and Handled escalated customer concerns and complex issues.
• Ensured a high level of customer satisfaction and service quality.
• Reviewed customer feedback and implemented service improvements.
• Collaborated with customers and stakeholders to resolve issues efficiently.
• Documentation Management
• Maintained compliance with service-level agreements (SLAs).
• Handle Scriptmed, CRM and Epost
• Medical Claims on RCm
• Delivered ongoing coaching to improve employee performance.
• Offer support to agents and SME's
• Assigned and Reassigned tasks to every agent

Customer Medical Service Advocate - CONCENTRIX- CIGNA INSURANCE - Remote, TX

(2024-06 - 2025-06)

• Assisted members and healthcare providers with coverage determinations, pharmacy claims, and benefits inquiries through the Evernorth platform
• Processed and managed claim appeals and denial reviews utilizing OneView and Salesforce systems.
• Coordinated with internal departments to reassign and escalate cases, ensuring timely resolution of customer needs.
• Provided comprehensive support to members regarding insurance plans, coverage options, and benefit eligibility.
• Handled prior authorization requests and medication determinations accurately and efficiently while maintaining compliance with company guidelines.
• Utilized multiple systems, including MARx, OneView, Salesforce, and Pivot, to research, document, and resolve customer inquiries.
• Earned certification in medical supplies and coding, enhancing knowledge of healthcare products, services, and regulatory requirements.
• Maintained a high level of customer satisfaction by delivering professional, empathetic, and solution-oriented support.
• Collaborated with cross-functional teams to resolve complex issues and improve customer experience.
• Documented customer interactions and case resolutions accurately to ensure compliance and continuity of service.

Customer Service Representative and trainer - Electronic Solutions TX - Remote, TX

(2021-04 - 2023-11)

• Assisted customers with account payments, billing inquiries, and payment processing while ensuring a positive customer experience.
• Managed payment arrangements and payment plans, helping customers maintain account compliance and resolve outstanding balances.
• Scheduled service installations and coordinated appointments to ensure timely service delivery.
• Trained and onboarded new team members, providing guidance on company procedures, systems, and customer service best practices.
• Utilized Microsoft Office applications, including Outlook and Excel, to manage communications, maintain records, and generate reports.
• Processed billing transactions and maintained accurate customer account information through company billing platforms.
• Collaborated with technical support and field service teams to coordinate on-site assistance and facilitate prompt issue resolution.
• Maintained detailed documentation of customer interactions, service requests, and account updates.
• Delivered professional and effective customer support while meeting productivity and quality standards.
• Promoted customer satisfaction by resolving concerns efficiently and providing accurate information regarding services and billing.

Claims Processor - Teleperformance- MCH hospital - Remote, TX

(2018-04 - 2020-03)

• Processed and reviewed Revenue Cycle Management (RCM) claims, ensuring accuracy, compliance, and timely resolution.
• Managed appeals and investigated denied or rejected claims received from healthcare providers, insurance carriers, and other institutions.
• Resolved medical and pharmacy claim issues by analyzing claim information, identifying discrepancies, and coordinating appropriate corrective actions.
• Assisted members, providers, and stakeholders with a wide range of medical-related inquiries while delivering exceptional customer service.
• Reviewed prior authorization requests and denial determinations to support accurate claims adjudication and reimbursement processes.
• Utilized Salesforce, NCT, Zoom, Slack, and Microsoft Office applications to document cases, communicate with stakeholders, and facilitate efficient team collaboration.
• Conducted claim research and analysis to support appeals, reduce claim denials, and improve processing outcomes.
• Maintained accurate records of claims activity, appeals, authorizations, and customer interactions in accordance with company policies and regulatory requirements.
• Collaborated with cross-functional departments to expedite claim resolution and improve overall operational efficiency.
• Managed a high-volume workload while consistently meeting quality, productivity, and service-level standards.

Bachelor's Degree - Agricultural Engineering - UNIVERSIDAD AUTONOMA DE CHIHUAHUA (2017)

Certification - RCM Claims - TELEPERFORMANCE-MCH HOSPITAL TEXAS (2019)

High School Degree - Technical Computer (2012)