Bianca Ortiz

*** ******** ***** #**

Bronx, NY **475

646-***-****

acgbgi@r.postjobfree.com

SKILLS AND CAPABILITIES

Experience in using Microsoft Office, Internet, Type 35 WPM, Data Entry

Experience in using ISIS database, QNXT, iObserver, MEDCO, Caremark and V3 systems and various PBM’s

Ability to make sound decisions based on solid judgment, work under tight deadlines in a confident and calm manner

Ability to learn new computer programs and applications independently

Excellent written and verbal communication skills with great interpersonal skills

Ability to multi-task and work under pressure due to volume and urgent nature of calls

Eight plus years of a high volume call center

Ten plus years in customer service

Health claims processing experience

Team Lead representatives to ensure accurate and professional responses to membership

Some bi-lingual language spoken (Spanish)

Some knowledge in Medicare part- D and Medicare (CMS)

Thirteen plus years in Union Environment and Health Care Industry in Providing Healthcare Benefits

Knowledge of ICD9 and CPT codes

Ability to work under pressure and empathies with upset clients

Ability to remain Professional in and irate or hostile call environment

Flexible and adaptable to change

References provided upon request

WORK EXPERIENCE

Private Duty Companion 9/2012 to Present

New York, NY

Responsibilities include:

Assisting elderly with daily needs

o includes feeding, changing, washing, reading and personal companion

Assuring that nursing home attends properly to patient and meets all their needs accordingly

QCR III- RX and Medical/Customer Service Specialist 01/2005 – 09/2012

1199 SEIU

New York, NY

Responsibilities include:

Quality control reviewer

Team Lead Organization

Managing home care and durable medical equipment

Prior Authorization of Specialty Medications and Injectable Medication (J- Codes)

Providing Vendors for Members

Utilization Management Reviews

High volume calls with members, providers and vendors

Document all call contact in call tracking system

Research claims eligibility and claims history

Accurately and professionally respond to telephone inquiries regarding member benefits, claims and complex RX issues

Troubleshoot and identify and solve any issues within the Call center

Communication with Medco Specialty Care and Medco Representatives and Pharmacy Vendors

Create authorization for Medco home care services, Direct member eligibility and durable medical supplies and pharmacy

healthcare benefits utilizing MEDCO Health Care Solutions authorization database

Inform and educate members, providers, and vendors on protocols, new programs, plan improvements and/or modifications

Monitor and Assist Representatives with irate and problematic calls

Perform additional duties and projects assigned by management

Provider Relations Credentialing Analyst I 12/2003 – 11/2005

1199 SEIU

New York, NY

Responsibilities include:

Data Entry Processing

Credentialing Providers into syntonic database

Communication with providers on daily basis

High volume calls in provider call center

Reviewing doctors licenses, malpractice suits or other credentialing documents

Medical Claims Processor 2/ 2002 – 11/ 2001

1199 SEIU

New York, NY

Responsibilities include:

Processing Medical Claims

Utilization of ICD 9 and CPT Codes

Production of 100+ claims daily along with accuracy

Meet daily quotas in processing medical and hospital claims

Knowledge of Benefits and Eligibility

EDUCATION

HIGH SCHOOL DIPLOMA

Our Savior Lutheran High School Bronx, NY

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