Nestor E. Nazario Rosado
Melbourne
Summary
Results-driven health insurance professional with over 5 years of experience in clinical, appeals, grievance management, and policy evaluation. Proven ability to analyze complex clinical documentation, resolve appeals, and collaborate effectively with clinical and leadership teams. Adept at optimizing workflows, training team members, and enhancing operational efficiency to deliver exceptional outcomes.
Overview
9
9
years of professional experience
Work History
Senior Risk Management Professional
Humana
01.2023 - Current
- Identified and analyzed potential sources of loss to minimize organizational risk through in-depth evaluations of complex issues.
- Estimated financial impacts of losses and developed cost-effective risk controls.
- Collaborated across functions to assess and communicate business risks, influencing departmental strategy.
- Made independent decisions on technical approaches and project components, with considerable autonomy in determining objectives and solutions.
Risk Management Professional
Humana
01.2022 - 01.2023
- Assisted with minimizing risk exposure by reviewing claim validity and viability against coverage standards.
- Developed short-term goals and long-term strategic plans to improve risk control and mitigation.
- Trained staff in risk management policies and monitored compliance to control company liability.
- Promoted enterprise-level risk management practices and helped instill strong culture focused on protective policies and procedures.
Grievance Appeals Specialist
Humana
01.2021 - 01.2022
- Managed client denials by analyzing clinical documentation, determining appeal eligibility, and delivering final decisions in collaboration with clinical teams.
- Investigated and resolved member/provider appeals, preparing case files for Grievance & Appeals workgroup presentation to medical directors and leadership.
- Led provider outreach to gather necessary documentation and assisted in training team members on workflows and policies.
- Drafted adverse determination and approval letters for Utilization Management decisions.
- Evaluated internal policies to enhance operational efficiency, submitting cases for auditing to propose solutions for complex issues.
Call Center Representative
UnitedHealthcare
03.2019 - 12.2020
- Managed high call volumes while providing exceptional customer support and maintaining professional composure.
- Developed rapport with customers through empathetic listening skills, creating positive experiences even during difficult conversations.
- Handled escalated calls professionally, effectively resolving complex issues and ensuring client satisfaction at all times.
- Mastered multiple software systems for seamless navigation during calls, improving efficiency and reducing hold times for customers.
- Enhanced customer satisfaction by efficiently addressing and resolving inquiries in a timely manner.
Sales Associate
BestBuy
07.2015 - 01.2020
- Actively greet customers and offer assistance to understand their needs, guiding them to suitable computer products and accessories.
- Stay up-to-date on computer technology, product specs, new releases, and industry trends.
- Focus on meeting and exceeding monthly sales targets and metrics, including add-ons, protection plans, and accessories. Regularly monitor individual performance against these goals and adapt strategies to achieve them.
- Consistently recognized as the top performing sales associate in the department. Known for driving key metrics to record-breaking levels through strong customer engagement, in-depth product knowledge, and strategic sales techniques.
Education
Bachelors - Major in Nursing
Universidad Interamericana de Puerto Rico
Rio Piedras, PR06.2020
High School -
Antilles High School
Fort Buchanan, Puerto Rico06.2012
Skills
Case analysis
Policy Knowledge
Workflow Management
Data Analysis
Investigational product management
Critical Thinking
Quality Assurance
Leadership skills
Team Collaboration
Excellent Communication
Medical Terminology
Time Management
References
Available upon request
Languages
English
Native language
Spanish
Proficient
C2
Timeline
Senior Risk Management Professional
Humana
01.2023 - Current
Risk Management Professional
Humana
01.2022 - 01.2023
Grievance Appeals Specialist
Humana
01.2021 - 01.2022
Call Center Representative
UnitedHealthcare
03.2019 - 12.2020
Sales Associate
BestBuy
07.2015 - 01.2020
High School -
Antilles High School
Bachelors - Major in Nursing
Universidad Interamericana de Puerto Rico
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