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Click here or scroll down to respond to this candidateCandidate's Name
Street Address PHONE NUMBER AVAILABLE EMAIL AVAILABLEProfessional SummaryDedicated and polished Customer Service professional with over 10 years in call center and medical utilization experience, who is adept to handle various calls on a daily basis, multi-tasks and make quotas while consistently resolving client issues in a rapid manner.ExperienceCOORDINATOR, SPECIALITY SCHEDULER KAISER PERMANENTE 10/2021-PRESENTUtilizes established guidelines to schedule appointments for specialty departments by telephone.Answer any questions members may have pertaining to primary or specialty appointmentsConfirm and provide data for member appointmentsReview external referral information with members and provide appropriate contact information.Utilize and navigate HNConnect to gain access to member data.DENTAL ELIGIBILITY REP HUMANA 07/2023-10/2021Handled inbound calls from members inquiring about dental benefitsGenerated quarterly reports for Health Plans that showed percentage errorrates and overall quality scores for agents work.Advised agents and supervisors of areas of improvement and re-trainingwhen it came to errors and patternsResource for agents when needing assistance with questions or workloadQUALITY ASSURANCE AUDITOR RIVER CITY MEDICAL GROUP 10/2019- 06/24/2021Audited customer calls and authorization creation of over 20 agents dailyGenerated quarterly reports for Health Plans that showed percentage errorrates and overall quality scores for agents work.Advised agents and supervisors of areas of improvement and re-trainingwhen it came to errors and patternsResource for agents when needing assistance with questions or workloadQuality AssuranceUTILIZATION MNGNTMNT COORDINATOR RIVER CITY MEDICAL GROUP 2/2018-10/2019Created Medi-cal and Medicare authorizations for providers and patientsQuota based Data Entry of ICD- 10, HCPCS, service and procedure codesApproved and denied authorizations based on medi-cal guidelinesGenerated and faxed denial, modification, eligibility, delay, approval letters and notificationsEnsured authorizations were completed within appropriate timeframes based on contractual guidelinesRequest clinical records if necessary for authorization completionMedical CredentialingCLAIMS EXAMINER I HEALTH NET 9/2016-09/2017Processed 120 plus Veteran Affairs (VA) and TRICARE Claims dailyReviewed claims to determine payableConfirmed valid ICD -10, CPT and HCPCS codes used on claimReturned claims to providers if pertinent information missingSubmitted request for re-issuance of checks if never receivedHEALTHCARE ELIGIBILITY REP HEALTH NET 6/2014-9/2016Handled 100 plus inbound calls from Medi-Cal and Cal Medi -Connect recipientsExplained difference between PPOs, HMOs and Fee for Service ( FFS )Submitted appeals and grievances on behalf of members and providersConfirmed enrollment and eligibility in state managed plansChecked claims status, reasons for denial of claim for providersEducationSEASIDE HIGH SCHOOL, SEASIDE CAHigh School Diploma, 2002HARTNELL COMMUNITY COLLEGE, SALINAS, CAAttended 08/2002-06/2004SACRAMENTO COMMUNITY COLLEGE, SACRAMENTO, CAAttended 08/2004-06/2005 |
