Call Center Los Angeles
Resume:
Ivonne Castro
Temple City, CA
Summary:
● Dedicated and resourceful Healthcare professional with a strong work ethic and excellent breadth of experience with members, providers, health plans, insurance brokers, collection.
● Handle Call Center member services, Utilization Review, Provider Enrollment and Provider Credentialing services, on-hold claim values, streamline and standardize administration processes as well as save time while ensuring compliance and training and education of healthcare providers
● Strong negotiation and presentation abilities in a variety of languages and cultural environments. Education:
East Los Angeles Community College, Los Angeles, CA - 2000-2001 Alhambra High School - 1995-1999
Skills:
● Bilingual, Spanish, Oral and Written
● Provider Enrollment/Contracting and Credentialing service
● Members, providers, insurance brokers collection
● Excellent written and verbal communication skills
● Exceed HEDIS, Adherence and Quality Audit goals
● Proficient in Microsoft Word, Excel, and PowerPoint
● Knowledge of contracts, applications, and network products to assist providers
● Authorization status for provider’s office
Professional Experience
Caregiver
Sole care giver of my recently departed father: December 2021-current Firm RCM
Workers Compensation Claims Rep July 2021-June 2024
Communicates claim activity and processing with the claimant and the client; maintains professional client relationships
Ensures claim files are properly documented and claims coding is correct
Refers cases as appropriate to supervisor and management
Subject matter expert of appropriate insurance principles and laws for line-of-business handled, recoveries offsets and deductions, claim and disability duration, cost containment principles including medical management practices and Social Security and Medicare application procedures as applicable to line-of-business
Excellent oral and written communication, including presentation skills
PC literate, including Microsoft Office products
Analytical and interpretive skills
Strong organizational skills
Excellent negotiation skills
Good interpersonal skills
Ability to work in a team environment
Ability to meet or exceed Performance Competencies
Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines
Physical: Computer keyboarding, travel as required
Auditory/Visual: Hearing, vision and talking
TwinMed, LLC
Customer Service Rep Feb 2020-June 2021
● Work in multi-channel support environment of phone, emails, and online live chat simultaneously.
● Process Inbound/Outbound calls and resolve customer issues in a timely and effective manner
● Order processing and input in Great Plains
● Order monitoring - provide delivery information on open orders and product inquiries
● Help customers locate products and check available inventory
● Maintain order corrections, notify customer of pricing errors and back order communication
● Issue Return Authorizations and process returns
● Provide new accounts with consistent communication via all forms including phone, fax, online, and email.
● Maintains and develops accounts by checking buying history, suggesting economical alternatives, explain specifications/feature/benefits on products
● Accomplishes department goals by accepting ownership for accomplishing new and different requests.
● Other job duties as required.
Network Medical Management, Alhambra, Ca September 2012 to February 2020 Call center member services, UM Review Coordinator, PNO
● To implement the effectiveness and best practices of Utilization Management and provide UM functions and department support to comply with NCQA and Health Plan standards.
● Responsible for verification to include but not limited to: benefit matrix through DOFR, eligibility, provider status
(contracted/non-contracted), carved out and others.
● Sort, stamp and distribute to UM Coordinator Level II & III of all incoming referral request, prints & etc.
● Training and education of healthcare providers.
● Verification of the providers credentials are done by contacting the “Primary Source”,
● Process Routine & Urgent treatment authorization requests according to the NMM Policy & Procedure
● TAT guidelines and meet daily production standard of minimum of 100 referrals/day with accuracy & quality
● Initiated Provider Contracts clearance to Provider Relations department and additional provider requests, reimbursement methods
● Work collaboratively with providers, hospital networks, billing services, and vendors to provide adequate service for the provider community
● Responsible for following up on tracking pre-certs and outpatient surgery schedule as needed
● Attend to provider and interdepartmental calls in accordance with exceptional customer service Call Center Representative I –Medicare
● Assisted members with Transportation and Member services calls. Scheduled transportation for PCP appointments, Pharmacy, Specialist, etc.
● Assisted members with PCP changes, provided authorization status for provider’s office and members.
● Assisted with filing grievances and appeals on member’s behalf. Provided information in regards to prescriptions on formulary, evidence of coverage, claims status etc.
● Provided stellar customer service.
Network Medical Management (assisted Department)
Provider Relations Coordination
• Verify provider web portal application, such as run NPI/License, TIN # in national database and internal PNFE/PIMS database to confirm they are contracted providers. • Create Blue Shield Promise Web Portal access. • Email providers/facilities to notify of web portal login ID and Password. • Initiated Provider Contracts clearance to Provider Relations Department and additional provider request, reimbursement methods such as Prop 56 and etc. • Assist with Terminating providers contracts per their request. Update provider’s site information, address, phone numbers, fax numbers. Also assisted with transferring members to another PCP due to PCP terming with IPA and/or keeping members with the same PCP but transferring to a different IPA. • Verification of providers completing SNP Model of Care training a requirement from CMS. Member Services Rep-APC and Sub IPA’s CS - LaSalle Lead (Network Medical Management)
● Assisted with supervision of 20+ employees, following established procedures, assist staff to direct patients in an empathetic and caring manner, efficiently and timely, and completes appropriate documentation.
● Assist representatives with daily telephone calls from members, providers, health plans, insurance brokers, collection and research and resolve authorizations, claims, and eligibility, concerns and assists staff with resolving any and all issues
● Processed Provider Agreements and contracts
● Elicit information from members/providers including the problem or concerns. Member Services Rep (Network Medical Management)
● Under general supervision, following established procedures, assist and direct patients in an empathetic and caring manner, efficiently and timely, and completes appropriate documentation.
● Responds to provider inquiries and attempts to resolve provider concerns or refers to management for resolution.
● Answer all daily telephone calls from members, providers, health plans, insurance brokers, collection agents and hospitals.
● Elicit information from members/providers including the problem or concerns.
● Research and resolve authorizations, claims, eligibility, concerns and resolve.
● Member/Provider Service/Representative assists Supervisor and Manager with other duties as assigned.
● Member outreach communications via mail or telephone.
● Initial Health Assessments sent to members, as needed. Altamed Health Services, Monterey Park Ca. January 4, 2016 to September 2016 Application Coordinator- Marketing Dept.
● Certified Covered California Counselor. Enroll individuals into Altamed provider/ medical clinics.
● Process inbounds and out bound calls with applicants and help assists selection of health plan and provider.
● Answer provider inquiries regarding verification of benefits and Claims status.
● Enrolling provider in a public health plan and the approval to bill the agency for services rendered.
● Requesting participation, completing the credentialing process, submitting supporting documents and signing the contract
● Provider Enrollment and Provider Credentialing services, on-hold claim values, streamline and standardize administration processes as well as save time while ensuring compliance
● Assist clients with PCP changes, authorization and referral info / status, etc.
● Initiated Provider Agreements to Provider Relations department and additional provider requests, reimbursement methods
● Communicate with Health plans, Covered California, Medical, Cal-Optima, Health net and LA Care.
● Performed other related duties as assigned and directed by my supervisor and marketing management. References available upon request
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