YOLANDA C. GONZALEZ

MEDICAL CLAIMS SPECIALIST/APPEALS & RESOLUTION

DATA ENTRY/REVENUE CYCLE/CUSTOMER SERVICE

CONTACT

Address: **** ******, *******, ** ***** Email: adw0pq@r.postjobfree.com

Phone: 713-***-****

CAREER OBJECTIVE

Highly motivated and dedicated professional individual with at least twenty years experience in the Medical Claims and Customer Serivce field. Seeking an opportunity to work with a company that is in demand for individuals who have acquired Skills, knowledge and experience. Also where I can demonstrate my positive communications and be a motivated team member.

EDUCATION

University of Houston-GED Equivalency

High School Diploma

May 1977 - Houston, Tx

LANGUAGE

English - FLUENT (Speak, Read, Write) Spanish - Fluent (Speak, Read, Write)

SKILLS TRAINING

Efficient in: Reading, retrieving info, emailing, filing and faxing reports, claims data entry 60 wpm, Appeals & Reconsiderations, Appeals & Grievance and computer literature.

Software experience: Windows, MS Outlook, MS Word, Excel, PowerPoint, MS Office, Citrix Trizetto, Facets, Macess, GEMs, Optum-Encoder Pro Expert, Nxtgen, Pluto coder, Epic, EMR/EHR, Provider Network search ERS, AS-400, Cubs system, Availity, Availability, Meditech, Mckesson, VPN, Aruba, ICD9/IC10, Non-Nofication Grid-NNG, CMS HCFA1500 & UB-04, CMS Prospective Payment System (PPS).

Highly self motivated with a positive attitude.

Excellent time management skills.

Strong work ethics and a quick learner.

Analytical and problem-solving abilites.

Prioritize, escalate or de-escalating issues.

Experience with ICD-10 and CPT coding.

Vaccinated for COVID-19 and Booster.

Ability to multitask and navigate multiple computer applications efficiently.

Empathetic with the desire and passion to help others / service oriented.

Effectively prioritize and execute tasks in a high-pressure environment.

Experience working in a team-oriented, collaborative environment.

Knowledge in handling PHI according to HIPPA laws, standards and regulations.

Experience working remotely, WAH (work at home) independently and without direct supervision

Private and quiet home office space for remote access work.

Access to high speed internet, smart devices and USB headset.

Exceptionally strong communication skills.

Expert organizational skills.

Ability to adapt to changing business needs.

Welcome and enjoy challenges.

Proficient in medical terminology.

WORK EXPERIENCE

Home Care giver for family member (self employed)

August 2022 - February 2023

. Provided total self care to disabled family member.

. Per schedule given I provided these services to the disabled female/family member: helped bathe, brush hair, helped dress, cooked meals, read books and mail, had daily conversations. I took her grocery shopping and to park walks. I used good communication skills with empathy, respect and consideration.

Anthem BCBS Medicaid-Contract - Mindlance Temp Agency - Houston, Tx

Appeals Reconsideration Analyst-Remote

October 2021 - May 2022

. Reviewed Provider Appeal letters and attached documentation received by mail or electronic to research denials for prior authorizations, Timely filing, Coding issues, Eligibility, Coordination of Benefits, Provider Network Status, Missing or Incorrect information and Medical Necessity.

. Processed Overturned or Upheld denials and Payments according to findings, responded to provider's appeals with electronic determination correspondence letters followed later with EOP.

. Processed correspondence letter to providers appeals to either allow more time or to request and resubmit with additional information to overturn appeals.

. Reviewed Providers NPI, TAX ID to determine if In or Out of Network.

. Researched Pluto Coder to determine code coverage guidelines and action to take.

Cigna Medicare Advantage-Contract - Mindlance Temp Agency - Houston, Tx

Customer Service Representative-Remote

May 2021 - September 2021

. Answer and manage incoming Member and Provider Calls.

. Manage messages, emails, fax, and follow up on missed calls.

. Start Members Grievance and Appeals Process.

. Follow-up with Member on Grievances.

. Process Lost or stolen Member ID cards.

. Verify/Process Annual Wellness/Stay Healthy Member Incentive Gift card status.

. Update demographic/gaurantor information with documentation or designated verbal obtained

. Update Member Primary Care Physician.

. Search In-network Providers per Member request, Call Providers to check availity.

. Verify that Medical Documentation received, update and route to corresponding dept.

. Verify benefits

. Change plan according to change of address region.

. Verified claim status.

Acclara Solutions LLC, 10713 W Sam Houston Pkwy N #500, Houston, Tx 77064

Customer Service Represenative II

November 2015 - December 2020

. Answer and manage Patient and Provider incoming Calls

. Manage messages, emails, fax, and follow up on missed calls.

. Obtain, verify, update, and coordinate patient insurance information.

. Generate billing statements.

. Inform patients of payment options and/or financial assistance if applicable.

. Collect Revenue payments from patients.

. Manage patient financial accounts and balances.

. Safeguard patient privacy and confidentiality

. Verify claims billing information with Providers.

. Submit grievance on patients request.

. Submit billing errors for corrections to Insurance follow up.

. Update demographic/gaurantor information with documentation or verbal obtained.

. Verify and submit updated information thru Epic for claims follow up.

. Verify that Medical Documentation received update and route to corresponding dept.

. Help members with use of provider portal.

. Knowledge of ICD9/ICD10.

Universal American Medicare Adv., 5450 NW Central Dr Unit 117, Houston, TX 77092

Customer Service Rep / Claims Examiner

June 2006 - April 2015

. Answer and manage incoming Member and Provider Calls

. Manage messages, emails, fax, and follow up on missed calls.

. Verify that Medical Documentation received update and route to corresponding dept.

. Process, input Provider prior authorization request and submit to UM dept.

. Process Lost or stolen Member ID cards

. Update demographic/gaurantor information with documentation or verbal obtained.

. Update Member Primary Care Physician.

. Search In-network Providers per Member request, Call Providers to check availity

. Provide Claims inquiry status.

. Explained Eligibility and benefits to Members and Providers.

. Claims data entry, Hospital UB04 and HCFA1500.

. Claims Processing of Hospital claims Inpatient, Outpatient, Home health, Rehab, Skilled Nursing, Behavioral Health, Dialysis and Professional and clinical claims.

. Processed Claims Appeals and Resolution.

. Verified all coding errors and Processed EOB to provider.

. Processed claims per investigation of Coding and authorizations. Submitted Expedited Medical Necessity Documentation to RN for approval or denial.

ACS Medical Billing (Company Closed)., 9800 Centre Pkwy, Houston, Tx 77036

Customer Service Representative

March, 2002 - February, 2006

. Answer and manage Patient and Provider incoming Calls

. Manage messages, emails, fax, and follow up on missed calls.

. Obtain, verify, update, and coordinate patient insurance information.

. Generate billing statements.

. Inform patients of payment options and/or financial assistance if applicable.

. Collect Revenue payments from patients.

. Manage patient financial accounts and balances.

. Safeguard patient privacy and confidentiality

. Verify claims billing information with Providers.

. Submit grievance on patients request.

. Submit billing errors for corrections to Insurance follow up.

. Update demographic/gaurantor information with documentation or verbal obtained.

. Verify and submit updated information thru Epic for claims follow up.

. Verify that Medical Documentation received update and route to corresponding dept.

. Help members with use of provider portal.

. Knowledge of ICD9/ICD10.

BCBS Of Texas / 1800 W Loop S #600, Houston, TX 77027

Customer Service Representative / Claims Adjuster

December, 2002 - February, 2006

Answer and manage incoming Member and Provider Calls

. Manage messages, emails, fax, and follow up on missed calls.

. Verify that Medical Documentation received update and route to corresponding dept.

. Process, input Provider prior authorization request and submit to UM dept.

. Process Lost or stolen Member ID cards

. Update demographic/gaurantor information with documentation or verbal obtained.

. Update Member Primary Care Physician.

. Search In-network Providers per Member request, Call Providers to check availity

. Provide Claims inquiry status.

. Verified Eligibility and Benefits.

. Claims data entry, Hospital UB04 and HCFA1500.

. Processed/Adjusted Hospital UB04 and Professional HCFA1500 Per UM requests.

. Verified all coding errors and Processed EOB to provider.

Contact this candidate