Clinical Review Coordinator/ appeals

PROFESSIONAL SUMMARY

SKILLS

WORK HISTORY

JOANNA RODRIGUEZ

PHOENIX, AZ 85044

480-***-**** advt4l@r.postjobfree.com

To seek and maintain full-time position that offers professional challenges utilizing interpersonal skills, excellent time management and problem-solving skills. Proficient in Microsoft Word, Excel, Power

Point, Outlook, Multiple Health Insurance

Websites; Excellent Customer Service; Strong

Interpersonal Skills

Authorization Input

Benefits Verifications

Regulatory Documentation

Insurance Authorizations

OSCAR HEALTH INSURANCE

Clinical Review Processor/Clinical Appeals Liaison Tempe, AZ March 2019 - October 2022 Intake, assessment, coordination of appeals, and liaising with several external agencies including state regulators and other third parties responsible for health plan administration and Oscar's internal Clinical Review Team

Assess eligibility of appeals, gathered case documentation and medical records to ensure that requested or established timeframe requirements are met Outreach to providers for medical records and to members as needed to gather details relevant to appeals

Coordinated with upper level management such as Medical Directors with level 1, 2 and 3 appeals in order to represent members' appeal accurately Advocated for members to ensure that members understood their appeal rights and had clear understanding of appeal process.

Ability to read, interprets, and analyzes documents such as reports, guidelines, plan documents and summary plan descriptions.

Responsible for training for all new Appeals Specialists on all Regulations and Operations MCKESSON HEALTH SOLUTIONS

Customer Service Representative/Insurace Specialist November 2017 - May 2018 Verifies insurance benefits for new patient referrals Re-verifies insurance benefits for existing patients Reviews all medical documentation against medical policy and initiates pre-determination, pre-certification, and authorizations

Follow-up on pending pre-certifications and/or pre-determinations Completes special projects as assigned

Performs other job related duties as assigned

Take inbound calls from patients to locate treatment providers. TOYOTA FINANCIAL SERVICES

Collections Customer Service Representative August 2016 - September 2017 Retrieving payment history from available systems and clearly communicating the status to the customer

Analyzing account characteristics and working with customers to resolve their issues, persuading them to bring their account current

Utilizing all collection tools available to maintain delinquencies and losses at or below Customer Service Center objectives.

MCKESSON HEALTHCARE

Reimbursement Insurance Specialist July 2014 - July 2016 Contact payers to verify patient eligibility and product specific coverage information Provide claims assistance, including billing and coding instructions, to physicians and/or office staff

Provide accurate and timely follow-up to all reimbursement inquires in accordance with program guidelines

Obtain and compile payer specific information for reimbursement database. AETNA

Claims Benefit Specialist February 2010 - October 2013 Claims processing for Mercy Care Plan and Illinois Integrated Plan Analyze and approve routine claims that cannot be auto adjudicated Coordinate responses for routine phone inquiries and written correspondence related to claim processing issues

Facilitate training when considered topic subject matter expert. HEALTH CHOICE OF ARIZONA

Claims Representative October 2008 - January 2010 Responsible for adjudicating incoming Institutional and Physician claims Give information regarding claims payment.

BLUE CROSS BLUE SHIELD OF ARIZONA

Claims Representative May 2006 - February 2008

Process Institutional and Physician claims

Explain to subscribers and group representatives contract benefits, and changes in coverage Give information regarding claims payment

Conduct research and updates on a current daily basis.

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