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Click here or scroll down to respond to this candidateCandidate's Name
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EMAIL AVAILABLECell: PHONE NUMBER AVAILABLE Home: PHONE NUMBER AVAILABLEProfessional Profile:Skilled bilingual individual with 10+ years of experience with Customers in a professional office setting and in medical environment.Ability to handle challenging customers in a professional manner.Extensive skills and knowledge in the Health field, Home Health Agencies, Nursing Homes and Medical Office.Case Manager experience.Human Resources experience.Strong qualities in organizational and communication skills.Knowledge in handling clerical tasks, office management systems and proceduresExperienced in using EMR, Medical documentation.Ability to collect, synthesize and research complex or diverse informationFamiliar with Medical Terminology and ICD9 codes.Responsible for documenting all communication regarding patient treatment and or physician office in patient medical record.Ability to interpret insurance explanation of benefits (EOB's) and compose and submit appeals to insurance carriers as necessary.04/01/2017-09/2018 Centra Care- Patient Financial Services (Contract Position thru K Force Staffing)Duties:Submitting claims for commercial Insurance.Processing Commercial Insurance.Processing the Modifiers to summit the claims.Make corrections, as needed for claim resubmissions.Prepare and send secondary claims daily, attaching primary EOBs when required.Credentialing of new and updated insurance payors.Adding the correct CPT codes and summiting It for billing.Reviewing and following up with commercials insurances that are requesting medical records and Re-summit the claims.Review and follow up with Commercial Insurances to verified why they are rejecting the claims.Explained to the patients the EOBs if they dont understand.Call Insurance and verified if Insurance are active and ask for benefits like, Coinsurance, Deductible, Patient responsibility, out of pocket maximum.Verified health Insurance policies for all major commercial carriers, as well as government healthcare agencies. I verify if the Insurance are active also I ask for benefits like, Coinsurance, Deductible, Patient responsibility, out of pocket maximum.01/2017-03/2017 Express-Scripts Pharmacy (Contract Position thru Pharmaceutical Strategies Staffing Temp for 3 month)Customer Service Specialist in the Pre-Authorization Department.Offer the best customer ServiceWorking in the Unit of the Pulmonary HypertensionVerify if patient has new Insurance and update the Information on fileNavigate daily through several platforms to research and accurately finalize claim submissions.Written communication with internal departments, members, pharmacies or agencies to resolve claim issues.Adhere to strict HIPAA regulations especially when communicating to others outside of Express Scripts.Prioritize and coordinate influx of daily workload for Copayment Assistance application that we process with patients, verify if they qualify for Copayment Assistant thru different programs.Returned mail and out-going correspondence and e-mails to assure required turnaround time is met.Assess accuracy of system adjudication and alert management of potential problems affecting the integrity of claim processing.Analyze claims for potential fraud by member or pharmacy.Work on special projects Returning call from patient regarding questions they have with their medication and delivery Issues.Contacting Physician Offices for them to renew the Prior Authorization for the medication.01/2009- 11/2016 Heavenly Golden Years Home Health Orlando FloridaPatient Coordinator (Case Manager)/ Office ManagerDuties:Clinical Administrator CoordinatorManaged all patient admissions and verified that all contracts were filed correctly.Case Review with RN.Knowledge of community resources and counseling/social work practices.Experience working with families in needsGood documentation skills.Ability to motivate others towards achieving goals.Knowledge in medical Insurance Enrollment Commercial and Government (Medicare & Medicaid).Ability to work in a variety of settings with culturally-diverse families and communities with the ability to be culturally sensitive and appropriate.Provide holistic and comprehensive case management services to all clients including: intake assessment, benefit assessment, goal setting, long-term care plan development, weekly case plan development, progress monitoring.Maintain a caseload of (25) families.Responsible for the confidentiality of all procedures and compliance with HHA /HIPPA.Verified of medical insurance of all patients.Quality assurance for all patients admitted and discharged.Oriented patient about Services and resources in the community.Created and maintained all absentees calendar, agency nurses schedules and staff meeting minutes.Oversaw implementation of patient management plans and emergency plans.Medical records, consultation with others professional, and diagnostic evaluation toassess client abilities needs and eligibility for services.Handling the Human Resources paperwork of all the employees continued Education, Insurances, vaccination, I9, w2 etc.Interpret insurance explanation of benefits (EOB's) and compose and submit appeals to insurance carriers as necessary.Responsible for contacting patients and insurance carriers regarding delinquent claims.07/2015 12/2015 Optum (UnitedHealth Care Account)Customer Service SpecialistDuties:Receive inbound calls from customers for:Annual Enrollment.Claims.Explanation of Benefits.Rx Benefits Detail.Complains Appeal and Grievances.Educate the member about the Medical Benefits.Update member LIS & PCP.07/2014 / 10/2014 Hotel Beds Orlando FLAccount receivables /collection (Contract)Duties:Posts customer payments by recording cash, checks, and credit card transactions.Posts revenues by verifying and entering transactions form lock box and local deposits.Updates receivables by totaling unpaid invoices.Maintains records by microfilming invoices, debits, and credits.Verifies validity of account discrepancies by obtaining and investigating information from sales, trade promotions, customer service departments, and from customers.Resolves valid or authorized deductions by entering adjusting entries.04/2012-09/13 Miguel Burgos MD P.A.Medical Records/ReceptionistDuties:Chart routing, organization, and scanning into EMR.Responsible for inserting all documentation in patient charts.Verification of insurance prior to patient appointmentResponsible for all front desk duties.Opening and closing of daily batches.Referral CoordinatorPre-screening patient and providing information to patient about physician and procedures.Booking appointments with Specialists that the primary PCP refers. Also, we make sure that all the referrals and booking management is carried out in agreement with company rules and regulations.Obtains physician approval for referrals and hospital admissions.Contacts insurance company for referral number or pre-certification/authorization.Schedules hospital admissions, outpatient procedures/tests and notifies patient of appointment and referral number.06/2007-07/2008 Wyndham Consumer Finance Orlando, FLCollection Executive (Call center)Duties:Collected payments and post to accounts.Reached out to customers with unpaid debt and attempt to collect from them.Maintained files on the financial status of accounts.Kept track of delinquent accounts.Set up repayment plans accordingly to ability to pay.Advised customers of default consequences and debt repayment policies.Updated information of customers in database.Compiled reports on delinquent account for management.Turned over accounts to attorneys.Disconnected services if account remains unpaid.08/2008-03/2009 Tempus ResortsCollection Executive (Call center)Duties:Collected payments and post to accounts.Reached out to customers with unpaid debt and attempt to collect from them.Maintained files on the financial status of accounts.Kept track of delinquent accounts.Set up repayment plans accordingly to ability to pay.Advised customers of default consequences and debt repayment policies.Updated information of customers in database.Compiled reports on delinquent account for management.Turned over accounts to attorneys.Disconnected services if account remains unpaid.Reported past due accounts to credit bureaus.Prepared statements for credit department.Education:University UNE,Orlando, FloridaBachelor in sciences, Clinical Psychology with a concentration in Gerontology, Children and adolescents.Pursuing the Clinical MSW in UNE University. |
