Call Center Quality Assurance

MARK KANG

Fair Oaks, CA ***** 916-***-**** *******@*****.***-

SUMMARY

Experienced call center professional trained in insurance policies, plans and coverage limitations. Remains calm and level-headed in fast-paced environments. Solves problems independently and teaches providers to use electronic systems. High-performing and systematic with excellent organizational and analytical abilities with focus on promoting loyalty.

SKILLS

● Inbound and Outbound Calling

● Customer Support

● MS Office proficiency

● Quality Assurance

● Software troubleshooting

● Problem-solving abilities

● Call Center Operations

● Customer relations

● Claims investigation and research

● Medicare and Medicaid eligibility

● Quality assurance

● File and records management

● Provider enrollment

● Accreditation information

management

● Insurance credentialing processes

● Teaching, tutoring and counseling

● Differentiated learning techniques

● Tutoring and after school help

● Behavioral/cognitive skills

development

● Reporting and documentation

● Classroom management

● Innovative lesson planning

● Curriculum development

● Special needs students

● Performance assessments

● Creative lesson plan development

● ICD-9 forms

● Clinical judgment

● Medicaid statutes and regulations

● Policy and program development

● Confidential case documentation

● HIPAA and confidentiality

● Medical billing and collections

EXPERIENCE

09/2021 to Current Customer Service Associate

Magellan Health Rancho Cordova, CA

● Listens and probes callers in a professionally and timely manner to determine purpose of the calls.

● Researches and articulately communicates information regarding member eligibility, benefits, EAP services, claim status, and authorization inquiries to callers while maintaining confidentiality.

● Resolves customer administrative concerns as the first line of contact - this may include claim resolutions and other expressions of dissatisfaction. 02/2021 to 09/2021 Case Manager

Kaiser Permanente Pleasanton, CA

● Investigates all issues, including collection of appropriate data, preparation, and presentation of documents to decision makers.

● Collaborates with internal staff, other MS Departments, managers, and physicians to seek resolution on issues and cases affecting member while ensuring compliance, documentation and enhancing members' experience.

● Meets time frames for performance while balancing the need to produce high quality work related to complex and sensitive member issues. 09/2020 to 02/2021 Provider Administration

VSP Vision Care Rancho Cordova, CA

● Monitor and maintain critical provider information in various VSP systems.

● Ensure requested information is delivered within the specified time frame and completed accurately.

● Create and maintain files for credentialing applications and renewals.

● Process and track new applications and renewal applications for all medical providers.

10/2019 to 03/2020 Appeals and Grievances Coordinator Blue Shield of CA Rancho Cordova, CA

● Gather necessary documents (from internal and external resources) related to an appeal, grievance, or complaint to develop a complete file.

● Required to communicate in writing with customers, members, providers, or designated representative, using the regulatory compliant format on all issues both for acknowledgment and resolution.

● Utilizes guidelines and review tools to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize and route to nursing and/or medical staff for review.

04/2017 to 02/2018 Eligibility Specialist

BRMS Folsom, CA

● Reviewed documentation for compliance with

requirements and accuracy of information.

● Contributed to and enhanced audit processes to maximize quality management standards.

● Developed and deepened relationships with providers and partners to maintain expertise and address problems.

12/2013 to 02/2017 Credentialing Specialist

Aetna West Sacramento, CA

● Obtained NPI numbers for providers and facilities and updated existing profiles.

● Conducted primary source verifications such as background checks and board certifications.

● Received and evaluated applications to look for missing and inaccurate information.

● Completed enrollments into Medicaid, Medicare and private insurance plans. EDUCATION AND TRAINING

08/1996 Early Childhood Education

CSUN Northridge, CA

05/2013

Medical Billing

MTI College Sacramento, CA

06/1999 Some College (No Degree): Early Childhood Education American River College Sacramento, CA

Contact this candidate