BRENDA M. ESTRADA-RIVERA

***** ****** *** **** ***** FL 33647 813-***-**** email address: adxp3i@r.postjobfree.com

SUMMARY OF QUALIFICATIONS AND SKILLS

Motivate, energetic, self-starter with exceptional skills. Compassionate about the medical /healthcare field.

Bilingual Spanish/English Language: Read, Write and Speak Fluently

Computer Skills –Proficient in Microsoft Word, Excel, PowerPoint, Access, Outlook, Teams, Emma, Pega, IKA Systems and Calyx Point Diamond Systems Rapids (Medical Notes), Emma, Care Connects, My Health Direct, Xcelys/ PEGA Systems, Trucare Medical Management, EMR Systems,CTRIX, OMNI, IKA Systems, CGX and ICUE Systems, AVAYA

Microsoft Office Outlook, Word, Excel, Teams

Customer Service and Verbal Communication; Loan processing, Documentation Reviewer

Medical Insurance (Knowledge of coding CPT Proc. Codes, ICD-9-10coding)

Filing Records, Abstract/Medical Records, Appointment Scheduling and Chart Documentation

Equipment Operation, Maintenance, Radiation Safety and Protection, Positioning and Procedures

PROFFESSIONAL EXPERIENCE

HUMANA HEALTH PLANS- CLINICAL OPERATIONS, (LANCESOFT AGENCY) TAMPA, FL NOVEMBER 2022-JANUARY 2023

CARE MANAGER, TELEPHONIC NURSE ASSISTANT 2- CONTRACT

Performed as the NAL Care Manager, Telephonic Nurse Assistant 2 in receiving inbound calls from members; calls in which includes providing reminders of preventive screenings, assisted with transferring calls to nurses, and answer general questions from members.

Duties consisted of utilizing established process, identify members appropriate for nurse intervention, knowledgeable about Humana systems, CGX application, MS Outlook, Teams, Word Excel ; guided members to in-network providers, answer general benefit questions, assist with basic access to care needs, and assist members with finding online tools, resources available through Humana.com and referring to support programs such as the Nurse Advice Line inbounds call center that provides Humana members with nursing advice.

Provided accurate and appropriate non-clinical guidance by utilizing available resources and benefits to ensure member is aware of and participating in all non-clinical programs and services offered.

Ensured members the awareness of system generated preventative health care services and educated Members with their plans; offer support with managing network participation by using your knowledge of members benefit plan and Humana approved resources in assistance was provided to members experiencing access to care issues.

UNITED HEALTH PLANS/OPTUM UM BEHAVIORAL TAMPA, FL APRIL 2022-SEPTEMBER 2022 CLINICAL ADMINISTRATOR COORDINATOR (REMOTE) Contingent

Worked within Utilization Review department gathering all data management and intake of referrals entered for clinical specifics to build authorization and pre-authorizations approval for clinicians and case managed patients.

Process administrative authorization requests submitted both electronically and paper within compliance timeframes, in various clinical platforms.

Serves as a liaison between call and clinical operation to investigate and resolve authorization conflicts that are submitted by claim processors.

Manually fax authorization letters to provider for members at IP facilities to ensure approval for patient’s transition of care.

Navigate and document multiple clinical applications and SharePoint sites

Submit Electronic Provider Updates request, verification, eligibility and demographics through NCQA, CAHQ, ICUE and CTRIX Systems.

Support internal business partner by email and handle all processing and documentation reviews.

AETNA/CVS HEALTH PLANS (ROSE INTERNATIONAL AGENCY) TAMPA, FL AUGUST 2021-FEBRUARY 2022 CLIENT SERVICES HEALTH SPECIALIST Contract (Remote)

Work with a team of specialists dedicated to one of our manufacturer partners to provide reimbursement support service Provided direct interaction with the manufacturer client to provide case statuses and updates.

PBM and major medical benefits, prior authorizations and appeals processing.

Detail-oriented with documenting cases clearly and accurately in accordance with the program guidelines. Good communication skills essentially for both internal and external.

Knowledge of Medicare benefits, Retiree enrollments and LIS assistance. Disability and Leave of Absence and compensation process. Plan and organized work assignments, set priorities and completes daily workload.

Adhere to the service policy and principles of the company, as well as the program guidelines set by the department. Communicates effectively and professionally with our program partners to assure the best possible service for our patients and partners.

AMERISOURCEBERGEN (MINDLANCE AGENCY) TAMPA, FL OCTOBER 2020-DECEMBER 2020 BENEFITS VERIFICATION SPECIALIST CONTRACT (Remote)

Reviews all patient insurance information needed to complete the benefit verification process and claims . Complete data entry and/or appropriate forms to document patient’s benefits coverage.

Triages cases with missing information to appropriate program associate.

Verifies patient specific benefits and precisely documents specifics for various payer plans including patient coverage, cost share, and access/provider options.

Identifies any restrictions and details on how to expedite patient access.

Documenting and initiating prior authorization process, claims appeals, etc.

Completes quality review of work as part of finalizing product.

Reports any reimbursement trends/delays to management.

Performs related duties and special projects as assigned.

HEALTH PLAN ONE TAMPA, FL (Remote) AUGUST 2020 –SEPTEMBER 2020

UNEMPLOYED (Covid-19) April 2020 –July 2020

BLUECROSS BLUESHIELD FL (APPLEONE AGENCY) TAMPA, FL AUGUST 2019- MARCH 2020 SALES COORDINATOR – CONTRACT

Processing of renewals letters and maintenance health items for Large Group Health insurance for clients.

Heavy volume work load consists of data entry, reviewing documentation, entering quotes with E-rates system for all renewals/new sales, corresponding forms, enrollments changes within database and excel /Access and all system updates through Diamond and CAHQ

Work consisted of cobra waivers, agency, group changes and all mailbox work requests processed in a timely manner.

Handled claims coded/processing and fulfillment auditing for all health, plans, renewal and new sales.

OHMSTAR HOME LOANS, TAMPA, FL SEPTEMBER 2018- JULY 2019

LOAN OFFICER TRAINING

Initial process of Loan verification 1003, 1008, Verification of Credits/Clients

Heavy volume of telephone interactions with customers/clients request and provided all Loan programs assistance

Responsible for the processing pipelines of loans with Calyx Point System to be credit approved and funded.

Worked closely Loan Officers, Underwriters and Clients on all conditions for approval

Set up and scheduled closing for completed files with title companies, developers and clients

WELLCARE HEALTH PLANS, INC, TAMPA, FL

CARE COORDINATOR/Telecommute FEBRUARY 2017-AUGUST 2018

Provides support for clinical care management, case and disease management, Behavioral and field service coordination staff.

HEDIS received list of care gaps from Wellcare and Medicaid/Medicare, conducted chart review via EMR system, Emma Medical System,, Care connects, IKA Systems and CTRIX.

Coordinated services for members (Medicaid/Medicare).

Produces formats and edits correspondence and documents. Responded to phones as assigned or team coverage with assisting Spanish speaking members.

Worked consisted of knowledge of CPT-4 and ICD-10, HCPCS, revenue codes, medical and insurance, contract terminology in verifications and processing claims. Abstract/medical Records

Organizes a variety of administrative and clinical tasks and prioritizes in order of importance and impact on members and providers.

Serves as a liaison in corresponding and communicating with providers and credentialing verification with systems CMS, NCQA, vendors and WellCare contacts and/or members representatives.

Interacts with other departments including Claims, Intake, Enrollment and Member Services to resolve member and provider issues.

Participates and supports nursing tasks, including but not limited to: faxes, discharge preparations, request of clinical information, and creation of authorizations if necessary.

Performed screening concerning members and prepared care plans, DME orders for coordination’s requested by Case Managers.

Performed provider research and verification.

WELLMED/UNITED HEALTH GROUP/ UTILIZATION MEDICAL MANAGEMENT, TAMPA FL

PATIENT CARE COOORDINATOR FEBRUARY 2016 –FEBRUARY 2017

Effectively supports Care Coordination programs and process with all nursing staff, Case Manager in the UM Medical Management Dept.HHS and ensures applicable program process and operational responsibilities are met; including with Wellmed Medical Directors, Physicians, hospitals and any other Health Plan or Msd external department

Documents all patient interaction in concise manner that is compliant with documentation requirement center for Medicare and Medicaid (CMS ) regulation

Responsible for the daily process coordination of weekly patient care committee (PCC) meetings and conference calls.

Review the CAQH system and download applications or supplemental documents as appropriate.

Maintain electronic provider files perform outreach to providers and facilities via phone calls and fax/email correspondence.

Demonstrate knowledge of credentialing regulatory and accreditation requirements (NCQA. CMS. Medicaid. etc.).

Conduct in-bound and out-bound calls for program requirements including, but not limited to patient; scheduling surveys/screenings reminder calls, transportation, census management with pending Long stay status of members to be discharged from hospital and skilled nursing facilities.

Perform on a daily basis by tracking Baycare and WellCare Census report with preparation on monitoring UM current in-patient cases in pend status, create authorizations, approve and refer to Case Manager -Nurses for clinical review Follow up with calls to reference all reporting of Baycare and WellCare discharges on cases with referral to transitional programs, skilled nursing facilities, status source of member/patients for hospitals/rehabs.

Worked with IKA System and Trucare Medical Management system in managing providers upload updates and member’s accounts updates and case managed and correspondence utilization.. Knowledge and usage all computer based programs such as; Microsoft Office and data based reports. EMR Systems- Abstract/Medical Records

Schedule and coordinates patient transportation, follow-up physician appointments in all applicable markets as needed.

Responsible for updating report and tracking a log of all nomncs for patients discharges at skilled nursing facilities maintaining collating, gathering and logs for Notice of Medicare Non-Coverage (NOMNC)

Worked with right fax electronically mail receipt for requested skilled Nursing and LTAC facilities and hospitals to create authorization approval, receiving clinical and requesting medical records. Intake of authorizations for clinical review

Processing referrals and claims with knowledge and usage of CPT-4 and ICD-10, HCPCS, revenue codes, medical, insurance, and contract terminology.

Performed all assigned duties including ; create through Trucare system authorizations upon request from hospitals, Skilled Nursing Facilities, Rehabs, DME, Home Health approve and refer to Case Managers/Nurses for clinical review and closure.

FREEDOM HEALTH PLANS/OPTIMUM (Medicare) TAMPA, FL

CONCIERGE SPECIALIST (Temporary) SNI Companies OCTOBER 2015-DECEMBER 2015

Responsible for maintaining highest level of service for our members by effectively assisting in daily activities with the objective of meeting production, timeliness and quality standards as well as medical, insurance, and contract terminology.

Participated with other health plan departments in planning, coordinating and problem solving in regards to claims operations

Ensured the delivery of superior customer services by providing timely and accurate claims payment and responding timely to member, provider inquiries, Vendors and complaints including Explanation of Benefits (EOB) and Explanation of Payments (EOP)

Knowledge of Medical, insurance, contract terminology.

Researched claims, reimbursements and appeals on claims denial with data input and knowledge of CPT-4 and ICD-10, HCPCS, and revenue codes

Escalated provider assistance, resolution and follow up

Created and arranged Excel files to run reports and utilization of other programs; MS Word, Access, Outlook

Worked with IKA systems/ IMG systems. Documentation performed on calls, including conducting LIS/EPACES verification and

using the LIS tracker

Effectively assisting the Concierge Team Supervisors in the daily activities of the department, ensuring order accuracy and resolving issues in a timely manner, and by fostering an atmosphere of teamwork.

Cross trained in all product lines to facilitate assistance for all departments

Handled escalated calls by assisting member with a viable resolution resulting in a win-win for the business and the member

WELLCARE HEALTH PLAN, INC TAMPA, FL

QUALITY IMPROVEMENT CARE GAP /POST PARTUM COORDINATOR OCTOBER 2012-JULY 2015

(Spanish Bilingual) Transition CTM

Conduct telephone outreach to Medicaid and Medicare members who are identified as needing Preventive services in support of Quality Improvement and regulatory/contractual requirements;

Provide education to member and their family about preventive health screenings while identifying barriers to care with the assistance of health plan procedures by informing Providers about the Care Gap(s) member has and why they are being seen.

Receive inbound calls from members and providers with questions on their care gaps, appointments, and benefits, complaints with other inquiries by responding in a professional and timely manner

Interacted with other departments to resolve and respond to members’ complaints, provider’s, vendors and other inquiries via telephone, correspondence and emails.

Scheduled doctors’ appointments for all household members including Spanish speaking member with their Primary Care Physicians (PCP) and/or Specialist to access needed preventive care services and close gaps in care via-three-way phone call.

Arrange transportation for member as needed. Refer to CM/DM as appropriate

Review and document all actions taken regarding contact related to members’ information by using Emma Access database and

Care Connects and Xcelys/ PEGA System

Loaded professional contracts into Diamond Systems, through appropriate research verification and provider data analysis

Collect and verify information concerning eligibility, provider’s status and claims through CMS and NCQA Systems

Records, investigates and resolves complaints as detailed with CTM Policies and Procedures (Referenced with claims completion of service), benefit coverage and Coordination of Benefits

Assist with special project assigned as back up support for the postpartum team and performed as (Bilingual) Care Coordinator with the Quality Improvement Team at WellCare Health Plans. Familiar with HIPAA compliance rules; maintaining strict confidentiality

Work consisted with improving Medicaid Hedis Scores by supporting providers in population management work and engaged members in managing, maintaining or improving their current state of health with education and counseling program guidelines,

Tracking clinic users via an existing software system (Emma Systems); documented all actions in case manage notes.

Assist patients in advocacy and resources for their healthcare needs. Demonstrate initiatives problem solving skills using judgment

Reviewed claims authorization with CPT-4,ICD-10, HCPCS and created screening for postpartum gap in care by telephonic outreach to member and closed gap

UNEMPLOYED/ JOB SEARCH/TEMPORARY POSITIONS HIREGY AGENCY APRIL2012 –SEPTEMBER 2013

CELPA CLINIC/R&S SERVICES TAMPA, FL

Medical Assistant/Administrative/Internship JANUARY 2009-MARCH 2012

Experience working at front desk and back office

Prepare rooms for exam and intake of charts documentation for patients

Clinical assisting doctors with patients/Triage

Scheduling appointments and answering phones

Handled all diagnostic referrals with knowledge in reading X-Ray, MRI, Lab Test Reports

Verify Insurance, knowledge of all medical, insurance, and contract terminology.

Worked with Medical software and notes with knowledge of CPT codes; CPT-4 and ICD-10, HCPCS

Prepared medical records per request for patients and Physicians’ offices

COUNTRYWIDE HOME LOAN/WELLS FARGO MORTGAGE DIVISION TAMPA /CLEARWATER

Mortgage Loan Specialist MAY 2006-DECEMBER 2008

Initial process of Loan verification 1003, 1008, Verification of Credits/Clients

Heavy volume of telephone interactions with customers/clients request

Responsible for the pipelines of loans to be credit approved and funded

Worked closely with loan officers and customers on all conditions for approval

Set up and scheduled closing for completed files with title companies, developers and clients

CTI CONSULTING CLEARWATER, FL

Marketing Consultant/Administrative JANUARY 2000-MAY 2006

Responsibilities include: office administrative duties, sales, and medical billing services

Consulting with Administrators of Hospitals and set proposals for hospitals on replacement and maintenance of their check signing business equipment’s

PAINEWEBBER, (BROKERAGE FIRM) NEW YORK, NY

Training Program Coordinator SEPTEMBER 1991-DECEMBER 1999

Worked with database administrator to develop and run reports

Attended corporate training meetings, special events planning, and coordination marketing meetings

Coordination of marketing brochures, scheduled and follow-up on the offsite and on-site technical training classes, extensive telephone contact with Branch offices and vendors

EDUCATION

10/2019-3/2020 Florida School of Insurance, Tampa, FL

215 Healths and Life Insurance Agent Pre-licensed

7/2008-5/2009 Ultimate Medical Academy Tampa, FL

Basic X-Ray Technician and Medical Assistance/Laboratory Program

Knowledge of Medical Insurance (Coding CPT Proc Codes, ICD-9 coding)

Internship hours completed (720 hours) - Graduated

1980 Hempstead High School, Hempstead, NY

Academic-Graduated –Diploma

CREDENTIALS/CERTIFICATIONS/ACHIEVEMENTS

HIPPAA Training/Cert

Medical Assistant and Laboratory Certification

CPR, First Aide, HIV Certification

Certified Notary Public

Certified Tax Preparer Seasonal

United Careers (medical billing certification online)

QI Clinical Hedis Practice Advisor Coding 101 Training

Customer Advocacy: Enhancing he Customer Experience Training

RXClaims Training

Volunteer for Metropolitan Ministries/Step out: American Diabetes Associates 2013-2015

240/215 Health & Life Insurance Agent Certification

REFERENCES UPON REQUEST

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