HECTOR MOLINA

***** ******* ** #* ****** Park, CA 91304 · 818-***-****

adbi50@r.postjobfree.com

Highly detail-oriented and organized candidate seeking a position that will provide a fast-paced, challenging environment and which will utilize my skills in information management, research, and communication services.

EXPERIENCE

ELIGIBILITY REPRESENTATIVE I, health net/CENTENE

september 2018 – Jan 2020 health net/centene woodland hills, ca

Liaison between third party administrators, employer groups and Health Net for individual membership enrollment and maintenance.

● Maintain accurate eligibility records for individuals and/or assigned employer groups

● Process all enrollments; plan changes, and disenrollment transactions

● Review aging to determine delinquent accounts, membership reconciliation issues from premium issues. Produce and distributes delinquent notices to members

● Communicate policies, procedures and benefits to employees, enrolled members or, if applicable, employers

● Provide cross training and back-up assistance to other enrollment groups

● Provide support within service operations as needed such as Membership Accounting

ELIGIBILITY REPRESENTATIVE I

SEPTEMBER 2016 – MAY 2018 TEAMHEALTH SUNRISE, FL

Data entry for hospital records for billing and eligibility research and update purposes.

● Processed eligibility related denials, correct and refile to the appropriate carriers and report denials that are unrelated to eligibility to Management

● checked patient’s eligibility status through the GE system, HDX Express, Hospital systems, and carrier/website eligibility systems.

● Referred to medical record face sheets if applicable for corrected insurance information and verifies eligibility to update and refile claims.

● Entered and/or updated patient demographics and insurance information within the patient’s account.

● Identified patient’s insurance and assigns, in priority order, the appropriate Financial Status Classification (FSC Patient Registration Rep

● Enters and updates patient demographics and insurance information in patient’s account.

● Prepares On-Base CCD (Chart Control Doc) for medical coder by ensuring all required fields are complete and accurate

● Identifies patient’s insurance and assign the appropriate Financial Status Classification (FSC) in priority order

● Add the related discount on the CCD for special billing arrangement per facility

● Add the appropriate invoice FSC in Fsc Flow field o the CCD based on accident indicator or special billing arrangement.

SMALL BUSINESS GROUP CASE MANAGEMENT REPRESENTATIVE II, health net

january 2003 – may 2016 health net woodland hills, ca

Small group administrator point of contact between Health Net’s internal customers (under writer, sales and account managers) for the proper new employer groups account set up and implementation.

● Review the accuracy of routing Group Sales Notifications (GSN) and supporting documentation prior to loading group into active status.

● Provide detailed feedback to Marketing and Underwriting regarding correctness and completeness of the GSN following established standards.

● Communicates with Marketing, Underwriting, and contacts to obtain clarification or resolve problems in processing.

● Load group level and rates onto Health Net’s ABS system for new and renewing accounts.

● Perform regular and periodic group maintenance as required.

● Request new plans and coverage codes from policy and contracts and follow to ensure correct code is received.

● Assign Policyholder ID’s and Group Suffixes to new accounts.

ELIGIBILITY REPRESENTATIVE I & II

Point of contact between account managers and employer groups to implement individual membership enrollment as well as department team mentor for new hires.

● Maintain an acceptable quality and production standards as outlined by the government regulations and department policies and procedures.

● Respond to all written and telephone eligibility inquiries from internal customers, (e.g. Sales, Underwriting, Appeals and Grievance, Claims Dept.) and external (e.g. Employer Groups, Members, 3rd Party Administrators, Brokers)

● Researched information on subscribers to resolve problems and or disputes.

● Conduct Monthly Audits to ensure accurate eligibility.

● Track, review and manually process enrollment transactions submitted by Sales and Service teams.

● Provide project support, new hire training and coordination of open enrollment processing as needed.

● Review eligibility reports submitted by Third Party Administrators. Identify all changes to eligibility (additions, terminations, and/or contract changes) and process all resulting transactions. Communicate actions taken and any discrepancies back to the Third-Party Administrator.

SKILLS

Bilingual Spanish/English

Proficient in IBM 8100 System with Windows wrap around, Microsoft Suite and Lotus Notes

Ability to meet the production and quality goals

Experience in Real State Telemarketing

EDUCATION

2006 PIERCE COLLEGE WOODLAND HILLS, CA

ENGLISH LIT

1997 LOS ANGELES TRADE TECH LOS ANGELES, CA Los Angeles, CA

AUTO TECHNICIAN

1994 CERRITOS BANK TELLER ACADEMY CERRITOS, CA Cerritos, CA

BANK TELLER

ACTIVITIES

Quality-focused, offering over 15 years of experience in data processing. Highly professional and meticulous, able to function well independently or as a team member of a professional administrative group. Analytical/data driven decision-making skills and excellent time management skills with ability to multitask in a fast- paced environment with excellent communication skills with all levels of the organization as well as outstanding organizational skills.

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