Seeking a position within the Health field that will be able to allow me to utilize my skill sets in order to develop
further experience within in a company to pursue my professional goals.
Relationship and team building Conflict resolution Patient/family focused Problem resolution ability
Knowledge medical terminology
Relationship and team building
12/2015 to Current
Grievance and Appeals SpecialistHumana Careplus Healthplans － Doral, FL
Address and resolve health plan member's and partner concerns directly, with regulators and with employers, reporting findings to the appropriate business and functional areas to drive process and provide resolution for member's.
Respond to complaints, grievances and appeals in a consistent fashion, adhering to all regulatory, accreditation and internal processing timelines and guidelines Collect, analyze and interpret trend information to address concerns members, physicians, hospitals, regulators and by providing effective and efficient service.
05/2014 to 09/2015
Molina Healthcare OF Florida
Provide computer entries of authorization request/provider inquiries by phone, mail, or fax.
Including: Verify member eligibility and benefits, Determine provider contracting status and appropriateness, Determine diagnosis and treatment request Determine COB status Perform action required per protocol using the appropriate Database Meet department productivity standards.
Respond to requests for authorization of services submitted to CAM via phone, fax and mail according to Molina operational timeframes.
Contact physician offices according to Department guidelines to request missing information from authorization requests or for additional information as requested by the Medical Director.
Provide excellent customer service for internal and external customers.
Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA) Participate in Care Access and Monitoring meetings as an active member of the team.
Meet attendance guidelines per Molina Healthcare policy Follow "Standards of Conduct" guidelines as described in Molina Healthcare HR policy Comply with required workplace safety standards.
08/2013 to 05/2014
Provider Services RepresentativeMolina Healthcare OF Florida － Doral , FL
Performed training for other provider services representatives as appropriate.
Engaged with high volume, high visibility providers to ensure provider satisfaction.
Support providers with various provider services functions such as receive, research and resolve provider inquiries with claims, eligibility and other inquiries.
Responsible to educate providers on the importance of changes to regulations, procedures and access to information.
Assists providers and educate them on Molina's claims training for various LTC (long term care) managed care programs such as Assisted Living, Adult Day Care, Home Health, Nursing Skilled facilities to ensure billing is correct and providers follow Molina's policies and procedures.
Engaged a strong communication with providers.
Responsible to advocate and support various providers services functions to emphasize on working with our external valuable providers.
Accountable to resolve providers claim and billing issues to a high level of care for our providers.
In charge to provide training in our Web portal on site visit with guidance to our new providers.
CMF's initiation for credentialing approval for records.
Education and Training
Technical School: Medical Administration Billing and Coding ATI Training Career Center － Doral , FL, USA
GED: High SchoolAmerican Academy Hisgh Shool － Miami, FL, USA
Assisted Living, benefits, billing, excellent customer service, Database, diagnosis, fashion, fax, functional, Home Health, image, Insurance, Assists providers, meetings, Access, mail, policies, reporting, research, safety, phone, trend, Web portal, provider orientation Long Term Care (LTC)