Medical Health
Resume:
DELIA A GARCES
Apt K* SAN ANTONIO, TX 78217
************@*****.***
Work History
TaskUS
Afterpay Campaign
Customer Service Agent
March 2019 - current
Assisting customers with accounts accessibility, order and payment information for their online purchases.
Aetna Health Care, San Antonio, Texas Grievance and Appeals Analyst Oct 10, 2016 - May 8, 2018
Processing verbal as well as written grievances by Medicare eligible insureds under the Medicare Part D plan and Medicare Advantage Plans coverage through Coventry Health Care now owned and operated by Aetna Healthcare. Duties included making outbound phone calls to Medicare Eligible members regarding their dissatisfaction and/or complaints regarding the Medicare Part D and Part C sponsored plan and/or processes. Ownership of approximately 30-50 cases per week. Cases assigned worked from onset through resolution. Either a call to the member for resolution or written correspondence was sent to provide a response within the Medicare designated time frame of 30 days from receipt of the complaint. Referenced Chapter Guidance to comply with Medicare's rules and regulations for proper responses to all member grievances.
United Health Group/WellMed, San Antonio, Texas Senior Claims Examiner Jan 26, 2015 - Oct 03, 2016
Processing medical claims, while researching member information as well as validation of accuracy in payments. Currently working in the Provider Dispute Resolution team, handling Provider Appeals, Complaints, and Grievances. Utilization of both email and electronic resolution to payment and contract discrepancies.
Aetna Health Care, SAN ANTONIO, Texas Medicare Grievance/Appeals Coordinator Jun 12, 2012 - Nov 19, 2014
Processing verbal as well as written grievances by Medicare eligible insureds under the Medicare Part D plan coverage through Coventry Health Care now owned and operated by Aetna Healthcare. Duties included making outbound phone calls to Medicare Eligible members regarding their dissatisfaction and/or complaints regarding the Medicare Part D sponsored plan and/or processes. Ownership of approximately 15-20 cases per week. Cases assigned worked from onset through resolution. Either a call to the member for resolution or written correspondence was sent to provide a response within the Medicare designated time frame of 30 days from receipt of the complaint. Referenced Chapter Guidance to comply with Medicare's rules and regulations for proper responses to all member grievances.
Peripheral Vascular Associates, SAN ANTONIO, Texas Insurance Collections and Billing Representative Feb 01, 2011 - Jun 01, 2012
Duties include, but are not limited to verifying payment accuracy, processing audits, submitting appeals, phone contact with all Texas Insurance Agencies for purposes of verifying eligibility and benefits. Billing claims in a timely manner and proper follow-up on status, via both telephone and internet. Maintaining the claims submissions for 4 separate physicians (approximately 500 rotating claims per month) relating to both Vascular Surgery and Podiatry.
Department of Health and Human Services, SAN ANTONIO, Texas Public Health Technician I Jul 01, 2010 - Dec 21, 2010
I assisted clients on Medicaid with medical transportation funds and medical transportation to and from Medical appointments. While employed I was able to gain knowledge of the Medicaid guidelines and rules and regulations of the state. Call center environment, taking over 90 calls per day. Computer skills and knowledge of the state HIPPA guidelines was a must.
UNITED HEALTH GROUP, SAN ANTONIO, Texas SENIOR CLAIMS ANALYST Nov 11, 2006 - Jun 20, 2010
Review and adjudicate medical insurance claims. Contacted hospitals and physicians as necessary to complete the task at hand. Studied the TRICARE plan and members benefits Review of high dollar and timely filing limits. I am also responsible in keeping in compliance with all state laws and regulations such as the HIPPA guidelines. I am currently processing approximately 100 claims per day on average. Self motivated with very minimal supervision.
USAA LIFE COMPANY, SAN ANTONIO, Texas HEALTH CLAIMS ADVISOR Oct 11, 1999 - Jan 12, 2003
provided investigation and adjudication of Medical Claims for the Health Line of Business as well as phone service to external customers for inquiries and verification purposes, while keeping current with the ongoing changes in the Health Care Industry. My responsibilities also included, but were not limited to: Facilitating daily Excel reports and Batch Balancing for the entire Health Claims Department, both paper type claims as well as automated claims transfer (ACT). Handle multiple tasks such as reviewing and responding to correspondence letters daily and systems such as Claim Facts, ERD, ODOCC, image, workflow, Excel, Microsoft, HAL, and Outlook.
PACIFICARE OF TEXAS, San Antonio, Texas CUSTOMER SERVICE ASSOC Sep 04, 1997 - Oct 07, 1999
Supported the Unit as a Team Lead/Mentor, as well as Customer Contact professional. Performed internal quality audits for all service and claims calls, in which provided suggestions for improvement to my peers when proven necessary. Serviced products such as Medicare Replacement Policies, Commercial Insurance, and HMO's. In addition, responded to customer inquires and complaints via the telephone or written correspondence.
HUMANA REGIONAL SERVICE CENTER, San Antonio, Texas CLAIMS ADJUSTER Feb 01, 1995 - Jun 25, 1996
Processed and adjudicated health claims for Major Medical, Commercial, Medicare, and Work-man's compensation policies. While employed with this company, I obtained a Certificate of Completion for Medical Terminology.
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