Program Coordinator Health Plan
Resume:
Bertie Aleman LVN
EXPERIENCE
Superior Health Plan
Program Coordinator
Aug 2023-July 2024
Verify eligibility. Verify provider is in network. Review proper paperwork is in place.
And information meets criteria. Medicare and Medicaid
Notify member with correct letter. Notify provider by fax.
Using TrueCare, Amysis and Provider contact.
Gonzaba Medical
March 2020-July 2023
Referral Nurse
Process referrals for power wheelchairs, prosthetics, and all medical equipment. For all 8 GMG clinics. Verify insurance. Review all orders with correct providers (in network), CPT and HCSPC Codes, and MD signature. Reenter with corrections into system and forward to PCP for signature.
Process approved referral, notifying patient and sending approval letter.
If request does not meet Medicare guidelines prepare for Medical Review. Obtain clinical, labs, or radiology.
Fax approvals to provider with patient demographics and appropriate clinical.
Molina HealthCare- Letter Team
June 2015 – March 2020
RU department.
Denial and Approval Letter Team for Marketplace, Medicare, and Medicaid. Pick out an appropriate letter templet.
Proof letters for any needed corrections.
Long Term Care
Humana, San Antonio-Authorization nurse
June 2010 - June 2015
Process provider Auth requests for Private insurance and Medicare
Using InterQual if request does not meet guidelines, prepare for Medical Review: obtain clinical from specialists, labs, or radiology.
Including processing denials with medical director instruction
Processing approval and denial letters.
Set up peer to peer.
Community First Health Plan— Case Manager
July 2005 - June 2010
Process referrals, responsible for special needs and diabetic members
Outreach to members to check on their status and needs. Medication, doctor appointments, follow ups, etc.
Identify patients that may be eligible for SSI. Notifying patients of patients, they may be eligible for SSI. Explain SSI.
Arrange social worker to patient to help with SSI paperwork. Follow up with parents.
South Texas Blood and Tissue Center- Apheresis Nurse
2000-2005
Processed possible platelet donors. Venipuncture.
Attach to automated machine to collect platelets.
Care of donors before, during and after automated donation.
Assess donors for any reactions.
Prepare product for the lab.
EDUCATION
SAISD Vocation School of Nursing, San Antonio, Tx.
LVN License
School Name, Golden West College CA
Nursing
Skills:
Medicare, Star, Star-Plus, Medicaid, Marketplace
Microsoft. Word, Excel. CCA, CMS, Athena, EZCAP, Availity
Milliman, InterQual
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