Bilingual Benefits Professional
Resume:
M. Lorena Jones
ab20tl@r.postjobfree.com
SUMMARY OF QUALIFICATIONS
** ***** ** ********** ** employee benefits/human resources
Bilingual (English/Spanish)
Experience with Access, ADP, Excel, Infinium, Kronos, Power point, and
Microsoft Word
Supervisor experience in the implementation of health, welfare and 401k
administration, vendor management and customer service
Project management and design to improve service and cost efficiencies
Proven customer service and interpersonal skills to enhance accuracy and
professionalism in the office
15 years medical office/health insurance background
Extensive experience with HMO, EPO and PPO health plans
Network Provider Contract Administration
PROFESSIONAL EXPERIENCE
Employee Benefits and Human Resources
Produce expense reports and claim forms for Exec U Care reimbursement
program for our executives based in Singapore, Macau and Las Vegas.
Assist employees with Dental and Medical claims resolution
Assist employees with incoming enrollments or plan changes as needed by the
employee
Experience with Access, ADP (Health & Welfare and Enterprise systems),
AS400, Infinium and Kronos.
Ensure compliance with our prenatal program
Manage 401(k) program including enrollments, loans and distributions
Audit invoices from TPA and other carriers for enrollment and billing
accuracy to ensure timely and accurate payment of invoices.
Network Provider Contract Administration and Negotiations for self-funded
group health plan.
Computer entry of new enrollments
Conduct bilingual meetings for Open Enrollment, new hires and newly
eligible employees
Executive and Corporate enrollments, COBRA Reimbursements and general
assistance
Benefits eligibility reports to determine employee monthly gain or
quarterly loss of coverage
Death claim submission
Medicare CMS Data Match processing
Medicare Primary Payer Debt Recovery Demand Notices
Class Action PBM client settlement submission
Research and finalize all employee appeals for benefits coverage in
situations where they did not enroll/add dependents to coverage.
Supervisor Experience
Hire, supervise and train all benefits department staff
Establish departmental procedures/processes for benefits administration
Planning and overseeing smooth process for Annual Open Enrollment meetings,
including staffing, supplies and meeting space requirements
Work closely with the Payroll Manager to ensure proper deductions of all
benefits related premiums or contributions and transparency between the two
systems
Respond to various Government agencies including District Attorney and
Medicare/Medicaid regarding employee benefits related matters.
Implement procedures/set up training binder to assist with training and as
a future reference tool
Conduct probationary period evaluations, annual employee performance
evaluations and counseling to review areas that require improvement
Produce Excel spreadsheets for annual financial audit, group health
participation, 401(k) and other voluntary benefits offered by the company
Responsible for reports and the collection/monitoring of receivables for
Leave Of Absence and FMLA employees. Keep accurate accounts receivable
records and receipts.
Project Management
Implementation of the benefits departments move toward a paperless
documentation system
Participate in the development and implementation of TPA Carrier changes
Work directly with Director to develop and produce monthly benefits
newsletter
Development of the company sponsored PPO network
Review, Edit and Approve all SPD's and Provider Directories
Vendor Management
Vendor manager of all TPA's for two PPO plans; a dental network plan;
outsourced STD, LTD and Life benefits and a 401kplan
Ensure COBRA compliance/Audit COBRA Reports from TPA
Vendor Management and maintenance of positive vendor relations
Work with vendors to improve processes, websites and reports to measure
results
Ensure departments compliance with HIPPA confidentiality regulations
Medical Office/Healthcare
Receptionist at the front desk
Collect co-payments or deductibles based on health plan provisions
Knowledge of medical terminology, ICD-9 and CPT Codes
Enter referrals and schedule appointments in computerized system (IDX
system)
Set up Home Health, Medical equipment, transportation or other services
for the patient after hospital discharge as requested by the R.N. Case
Manager
Obtain pre-authorization for surgery, testing and office procedures from
various insurance carriers
Verify insurance eligibility and benefits, answer billing questions for
patients
Translate for Spanish speaking patients as needed
Obtain copies of records as needed to assist R.N. Case Manager in hospital
discharge planning
Maintain high level of confidentiality
WORK HISTORY
Benefits Specialist, Venetian Resort, Las Vegas, NV
2009-Current
Benefits Administrator/Supervisor, Black Gaming Mesquite, NV 2007-2009
Benefits Administrator, Venetian Resort, Las Vegas, NV 2006-
2007
Benefits Supervisor, Oasis Resort-Casino, Mesquite, NV 2002-
2006
Pre-Auth/Insurance Retina Consultants, Las Vegas, NV 2001-
2002
Case Mgt. Asst., Sierra Health/ HPN, Las Vegas, NV.
1997-2000
Patient Service Rep., Sharp Healthcare, San Diego, CA 1989-
1996
EDUCATION
PHR Certificate-Prep/Study In progress, SHRM Self-Learning System 2011
Medical Receptionist Certificate, Cabrillo School of Nursing, Chula Vista,
CA.
High School Diploma, Mar Vista High School, Imperial Beach, CA.
M. Lorena Jones
ab20tl@r.postjobfree.com
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