**** ********* **. *** *******, CA. 90063
SUMMARY OF SKILLS AND QUALIFICATIONS
Bilingual: English/ Spanish
Proficient with computer software such as Microsoft Office applications (MS Word, Excel, Access) Experience in Healthcare Industry: Corporate / Administration principles, practices and techniques Provider Enrollment processing familiar with Government websites Problem solving Skills / Effective Communicator / Multi task within a deadline-driven environment
USC Care Medical Group-Keck Medical Center of USC
Provider Enrollment Specialist February 2018 to Current
Responsible for preparing submitting credentialed applications and supporting documentation for the purpose of enrolling new and continuing providers. Follow up closely on status of providers’ applications to Government sites. Familiar with Government websites (i.e. from Centers for Medicare and Medicaid Services (CMS-Noridian), Palmetto GBA (Railroad Medicare), Department of Health Care Services (DHCS-MediCal), Children’s Medical Services (CCS)
SynerMed – IPA (Independent Physician Group)
Authorization Coordinator (OBGYN, PEDS) February 2017 to June 2018 Authorizations : Modify request clinical notes from providers update into the patient’s file Medical Records : Responsible for complete and accurate documentation, coding Familiar with EHR/EMR
Care1st Health Plan 2013- 2017
Member Services Representative II
Receive phone inquiries through an Automatic Call Distribution & Management Information System
Responsible for responding to inquiries regarding plan benefits and coverage explanation or issues; including requesting that plan material, correspondence or special items be mailed to members as requested.
Responsible for complete and accurate documentation, coding and follow-up of all member issues, complaints/grievances in a timely and efficient manner Responsible for thorough follow-up and completion of all member and provider inquiries or requests; including member maintenance, eligibility confirmation or special assignments or projects as requested. Responsible for documentation into the CSC/CSIM data system regarding all issues and/or inquiries.
AltaMed Health Services Cooperation 2009- 2013
Customer service Internal/External Customers. Provided information to government agencies (DPSS, LACDHS, SDHS)/release Medi-Cal members from eligibility hold status. Initiate a high volume of phone calls to members for retention efforts Medi-Cal through the Redetermination process.
Responsible for taking complex member complaints and grievances and overturn/close them on a timely manner by the health plans and government programs policy. Conduct welcome calls and schedule the first initial physical assessment to our new FQHC and Non-FQHC enrollee’s to improve HEDIS measures.
Identify and coordinate enrollment from one managed care plan to another when members lose eligibility in one plan (i.e., from Medi-Cal, Medi-Care to Healthy Families or one of our Alta Med Programs when income level goes up or etc.).
Provide information to government agencies (DPSS, LACDHS, SDHS) release Medi-Cal members from eligibility hold status.
Maintain reports on monthly activity (e.g. On Hold, Re-Determination, CCS Dis-Enrollment, Senior Welcome Calls, and SPD Welcome Calls, Dual Eligible activity). Comprehensive knowledge of billing procedures
Enter, maintain, and retrieve data, reports, and information into records systems. Promote health service programs (services, clinic hours, locations, programs) Perform other related duties as assigned; knowledge of cpt codes, modifying authorizations.
Bingham McCutchen LLP 2004 to 2006
Lead Office Clerk (Williams Lee)
Supervised mail services team to ensure proper mail delivery; tracked and maintained accounting for all incoming and outgoing packages including RightFax. Processed all general service supply requests and placed supply orders from various vendors. Maintained monthly reports
Estrella Realty 2002 to 2004
Front office Clerk
Assisted in every facet of running office, including but not limited to, clerical duties, filing, calendaring appointments, heavy client contact (customer service), and data entry; assisted in filing paperwork for loans.
Answered incoming calls and questions from current and potential clients, agents, and other business associates.
Tracked and documented all business related communications, store/file according to company standards. Worked effectively with all support staff, management, and brokerage professionals.
Parks Huerta Primary Center 2003 to 2004
Teacher Assistant / Tutor
Performed one-on-one tutoring with students in varied subjects as deemed necessary to develop their academic skills. Collaborated with parents to achieve success for their children’s educational needs within the home and school.
Pio Pico Span School / After school Tutoring 2001 to 2003 Teacher Assistant / Tutor
Assisted in the educational development of children by aiding the Lead teacher in all classroom lesson plans and activities.
Created and facilitated various lesson plans to implement throughout the academic year. Assisted in enhancing students’ values and morals by implementing several positive behavior classroom activities.
Assisted the Literacy Coach with full responsibility in directing reading workshops. Gardena Alternative Education Center 1998 to 2001
School Office Assistant / Teachers Aide
Created lesson plans for thirty adolescents, and assisted in individual education plan. Facilitated student enrollment, pre-assessment and post educational requirements. Assisted teens with IEP goals within a group setting with daily assignments, organization skills, anger management, and to alleviate at-risk behaviors.
Maintained student files and case management notes Established an academic advisement program for high-school dropouts and students in danger of failing: dropout prevention and recovery strategies.
Identified student needs- by customizing each program, course, and curriculum to best meet each student needs.
Assisted director within the daily functions of our program, including parent teacher conferences. EDUCATION
Los Angeles City College, A.A. Sociology 2001
Available upon request