Zoila Flores Breeden
Newtown
Summary
Bilingual health insurance professional with extensive expertise in claims processing and auditing. Proven track record in managing teams and projects, enhancing operational workflows, and ensuring compliance with federal standards. Committed to delivering exceptional service and maintaining accuracy in complex environments.
Overview
17
17
years of professional experience
Work History
Account Manager
ECTS
01.2024 - Current
- Work directly with schools and libraries to guide them through the full review process of the E-Rate Program, ensuring compliance with federal guidelines and securing the maximum eligible funding.
- Advised schools and libraries on E‑Rate requirements for contracts, bids, and procurement; gathered required information and prepared, completed, and submitted applications and supporting documentation.
- Coordinate with service providers to ensure schools and libraries receive all discounts and reimbursements they are entitled to under program rules.
- Directed clients to appropriate accounting resources, managed incoming calls, and responded promptly and professionally to office emails, ensuring high-quality customer service.
- Organized and maintained accurate files for schools and libraries, including sales contracts, client interaction records, notes, and essential documentation.
TPA Project Manager/SME & Senior Claims Technical Lead
Smart Data Solutions
01.2023 - 01.2024
- Managed and supported multiple TPA client projects (BCBSAZ), including claim auditing, claims adjudication, logic mapping, billing configuration, and provider eligibility maintenance; served as Subject Matter Expert (SME) across adjudication platforms such as HEALTHpac, VBA, Javelina, HRP, Metavance, and WLT.
- Coordinated and delivered client-specific HEALTHpac claim auditing training, ensuring accuracy, compliance, and consistent application of plan rules to enhance client understanding.
- Lead and manage a team of 30 examiners and 5 auditors, overseeing claim examination, claim audits, monthly QA, and internal audit review of 1,500+ claims per month.
- Participate in the review and editing of plan materials, including SPDs, SBCs, and plan amendment documents, ensuring accuracy and regulatory compliance.
- Perform client‑specific logic mapping of all CPT/HCPCS codes to drive benefits across multiple claims adjudication platforms.
- Created comprehensive Standard Operating Procedure (SOP) documents to standardize processes.
Senior Claim Audit Team Leader
Smart Data Solutions
01.2021 - 01.2023
- Resolve complex or problematic claims in collaboration with the Claims Manager and Director of Claims, ensuring timely and accurate outcomes.
- Confirm correct system processing and determine appropriate payment according to the plan as written, identifying discrepancies and resolving processing errors.
- Verify the accuracy and completeness of all required documentation for each submitted claim, ensuring compliance with plan provisions and internal standards.
- Assisted Team Leader in resolving claim appeals and disputes by compiling and providing required documentation for review, facilitating timely resolutions.
- Participate in client and internal meetings to support operational alignment, process improvements, and client‑specific requirements.
- Supported internal audits and quality assurance activities, enhancing accuracy, compliance, and continuous improvement initiatives.
- Supported fellow auditors during high‑volume periods and served as designated backup during staff absences, ensuring workflow continuity.
Account Manager
ECTS
01.2019 - 01.2020
- Work directly with schools and libraries to guide them through the full review process of the E-Rate Program, ensuring compliance with federal guidelines and securing the maximum eligible funding.
- Advised schools and libraries on E‑Rate requirements for contracts, bids, and procurement; gathered and submitted all necessary applications and supporting documentation to ensure compliance and funding maximization.
- Coordinate with service providers to ensure schools and libraries receive all discounts and reimbursements they are entitled to under program rules.
- Directed clients to appropriate accounting resources, managed incoming calls, and responded to office emails promptly to enhance overall customer service experience.
- Organized and maintained accurate files for schools and libraries, including sales contracts and client interaction records, to support effective documentation and retrieval.
Marketing and Sales Support Manager
United Group Programs
01.2009 - 01.2019
- Processed new business proposals, including preparing RFP documentation, assembling enrollment kits for new and existing clients, designing marketing materials and presentations, and generating business reports for the CEO and VP of Sales.
- Supervised a team of four marketing and sales coordinator representatives, ensuring high‑quality customer service and effective support for internal sales operations.
- Provided the customer service unit with new group coverage documentation and maintained all marketing reports to support smooth onboarding and ongoing client service.
- Reviewed insurance claims and member eligibility to identify overpayment trends and non‑compliance issues, contributing to improved accuracy and cost control.
Education
Below College - Business Administration
Bucks County Community College
PA01-2004
Below High School -
William Tennent High School
PA01-1999
Skills
- Client Relationship Management
- Sales Strategy Implementation
- Customer Retention Strategies
- Strategic Account Development
- Performance Metrics Analysis
- Salesforce
- HubSpot
- Microsoft Office 365
- Excel
- PowerPoint
- Outlook
- Word
- SharePoint
- Cross-Functional Collaboration
- Attention to Detail
- Ability to Learn
- Team Player
- Communication Skills
- Member portals
Timeline
Account Manager
ECTS
01.2024 - Current
TPA Project Manager/SME & Senior Claims Technical Lead
Smart Data Solutions
01.2023 - 01.2024
Senior Claim Audit Team Leader
Smart Data Solutions
01.2021 - 01.2023
Account Manager
ECTS
01.2019 - 01.2020
Marketing and Sales Support Manager
United Group Programs
01.2009 - 01.2019
Below College - Business Administration
Bucks County Community College
Below High School -
William Tennent High School