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Click here or scroll down to respond to this candidateCandidate's Name
Street Address West Carver StreetLakeland, FL Street Address
PHONE NUMBER AVAILABLEEMAIL AVAILABLEOBJECTIVEObtain a position where communication skills, personality, and pleasant manner in dealing with customers and sensitivity towards the needs of others would be essentials and making a footprint in the healthcare industry. Strong history of successful projects using leadership, communication, and teamwork to complete any tasks.QUALIFICATIONSKnowledge of analyzing managed care products, family medical leave of absence, short-term disability, and long-term disability, process new enrollment eligibility for Medicare and Medicaid eligibility. Strong outstanding customer service, computer knowledge, ICD-10 codes, and verification of medical insurance, UB-92, CMS-1500, medical records, patient and insurance collections, premium billing and submitting and reviewing grievances and appeals protocols. Over 10 years of outstanding claim management, ERISA, third party administration, offsets, durable medical equipment policy and process and assisting with training new team members, process inpatient and outpatient prior authorization, set up and create peer reviews and handling complaints received through State or Federal regulatory agencies.EDUCATION1992 Miami Jackson Senior High2007 Certified Medical Biller2017 Associate Science2020 Health Coach2020 Notary Public2020 Project ManagementEMPLOYMENT11/2022- Present, Lead Program Coordinator, Sunshine Health, Plantation, FL Assists with developing workflows and daily assignments for staff Serve as a resource and help resolve complex issues Initiate authorization requests for output or input services in keeping with the prior authorization list. Maintain working relationships with other departments Research complex claims inquiries specific to the department and responsibility Attend ongoing training and in-services Promote member compliance such as verifying appointments, obtaining lab results. Assess and monitor inpatient census Screen for eligibility and benefits and identify members without a PCP and refer to Member Services. Coordinates services with community-based organizations. Assist with developing marketing and outreach meetings Produces CM letters and program educational materials Train new staff on systems, usage, benefits, authorization requirements and policies and procedures Maintains databases and data enters assessments and authorizations into the system.10/2021- 11/2022, Complaint Coordinator, Sunshine Health, Plantation, FL.> Receive, investigate, and respond to member and provider complaints including complaints received through State or Federal regulatory agencies. Assist with ensuring compliance with contractual requirements and federal and state government reporting and regulations.> Assist with the development, update and maintenance of complaint and complaint-appeals policies and procedures including member, provider, and regulatory complaint correspondence.> Review and audit complaints against the complaints process and procedures.> Maintain complaint and complaint-appeal logs to include all contractual and regulatory-required information.> Receive, process, track and maintain all member, provider and regulatory complaints and complaint-appeals.> Maintain compliance with contract deliverables, state contract with the Health & Human Services Commission (HHSC) and all state and federal regulations.> Coordinate applicable internal and external customers to obtain the necessary documentation and information necessary to respond to a complaint or complaint-appeal.> Gather, analyze, and report verbal and written member and provider complaints, grievances and appeals.> Prepare response letters for member and provider complaints, grievances and appeals.11/2016 10/2021, Referral Specialist II, Centene - Medicare, Sunrise FL.> Initiate authorization requests for discharges, outpatient and inpatient services in accordance with the prior authorization list. Route to appropriate staff when needed.> Utilization review or claims processing practices in a managed care environment.> Verify eligibility and benefits and assist with training new team members.> Answer incoming phone queues and process faxes within established standards.> Submit authorizations into the system.> Receive and effectively respond to external provider related issues and staffing and updating vendor changes and processes.> Handling incoming prior authorization request.> Set up and create peer reviews.> Receive, process, and data entry all authorization requests for physician, ancillary providers and internal requests to determine approval or denial as directed by the Medical Director.> Investigate, resolve and communicate provider claim issues and changes.> Educate providers regarding policies and procedures related to referrals and claims submission, web site usage, EDI solicitation and related topics.> Identify members without a PCP and refer to Member Services. Screen members by priority for case management (CM) assessment. Perform transition of care duties to include but not limited to, contact the members attending physician, member or medical power of attorney, other medical providers (home health agencies, equipment vendors) for information pertaining to special needs.01/17/2007- 1/2016, Aetna Disability Specialist, Aetna, Sunrise FL.>Verifies STD coverage, evaluates information received, calculates, adjusts and pays benefits and assist with training new team members.>According to plan or state provision, identifies other income sources.>Documents claim decisions and actions, enter data into claim processing systems.>Utilizes customized scripts to set up new disability claims via telephonic.>Coaches callers on benefit types and next steps needed.>Responsible for obtaining clinical data information from Physician's offices via phone and fax.01/2004 12/2015, Customer Service Rep., Vista Health Plan, Sunrise, FL> Handled incoming calls regarding member benefits, assist with PCP changes, updated account information.> Assist provider resolving claim issues, verification of benefits, able to identify CPT, ICD-9 codes and assist with training new team members.2000-2003, Customer Service Rep., Neighborhood Health, Miami, FL> Handled incoming calls regarding member benefits, assist with PCP changes, updated account information.> Assist provider resolving claim issues, verification of benefits.> Able to identify CPT and ICD-9 codes, process new enrollment updated premium billing inquiries; monitor inbound and outbound calls when production was higher than normal and assist with training new team members.2000-2000, Payroll Clerk, Budget Quality Staffing, Miami, FL> Enter employees sick and medical leave of absences in IBM payroll system for State of FL.> Analyze and resolve payroll issues for employees.1998-1999, Customer Service Rep., Topp Telecom, Miami, FL> Handled incoming calls regarding account.> Updating customer Information, assist with customer care calls.1996-1998, Data Entry Clerk, ABC Distributing, Miami, FL> Handled catalog orders, sorting mail orders, update account information.> Related clerical duties on a daily basis.REFERENCE |
