Customer Service Administrative Support
Resume:
ESTELLA MENDOZA
ADMINISTRATIVE SUPPORT SPECIALIST
CONTACT
****************@*****.***
Stockton, CA 95207
OBJECTIVE
Detail-oriented professional with 15+ years of experience and a proven knowledge of Healthcare and Customer Service communications, workflow prioritization, and back- office operations. Aiming to leverage my skills to successfully fill a Healthcare Administrative Support role at a Medical Facility. SKILLS
BI-LINGUAL:
ENGLISH/SPANISH
60 WPM
MICROSOFT OFFICE
CUSTOMER SERVICE
SELF-STARTER
TEAM PLAYER
SALESFORCE
VISTA AS400/ACS
PACS
ATHENA
STOLIS
MEDI-TECH
ALEGRA SYSTEMS
CITRIX WORKSPACE
CISCO FINESSE
EXPERIENCE
CARE RESOLUTION SPECIALIST (Kaiser Permanente)
Medasource, Indianapolis, Indiana / April 2024 – December 2024 The Continuity of Care (CoC) Hub team was formed in October 2023 with the purpose of supporting Medi-Cal enrolled members impacted by the transition of care to Kaiser Permanente effective January 1, 2024.
Ensured all member decisions related to continuing care with Out of Network
(OON) Providers, or transitioning care within the Kaiser Permanente network, are honored.
Followed Continuity of Care (CoC) Reference Document Flowsheets.
Reached out to OON Providers and documenting their continuity of care decisions.
Ensured written documentation was sent timely to all impacted parties, Patients and OON Providers.
Case Management liaison for members, their representatives, and providers with questions regarding continuity of care.
o Proactively monitored patients with complex medical conditions to ensure timely intervention and appropriate care, updating patient’s charts.
Assiduously and accurately documented all members, member representative, and provider contacts.
Consistently prioritized quality care outcomes through diligent chart reviews, outreach, and coordinated care between departments and organizations.
Responsible for ensuring Continuity of Care regulatory guidelines as set forth by the Department of Health Care Services (DHCS) are strictly adhered to.
Contributed to bi-weekly reports submitted to Department of Health Care Services (DHCS).
Supported medical chart reviews and document collection in support of regulatory audits with the Department of Health Care Services (DHCS). REFERENCES
Available upon request.
AUTHORIZATION SPECIALIST
Myriad Genetics Laboratories, Salt Lake City, Utah /Feb 2022 – Nov 2023 Verified patient insurance coverage timely utilizing phone or online resources. Submitted prior authorizations to insurances in timely matter via payer specific portals and vendors.
Ensured all pertinent medical documentation was accurate and present prior to authorization submission.
Followed up with pending authorizations on a regular basis to obtain the status or to be informed of any action needed to obtain the authorization approval.
Communicated any authorization denials to the appropriate staff.
Handled any discrepancies, errors, or omissions of authorization denials and files appeals when necessary for overturn of adverse decision.
Participated in educational activities and attends regular staff and department meetings.
Exhibited and managed excellent turn-around time to ensure timely authorizations.
Demonstrated flexibility to perform duties wherever volume deemed it necessary.
Documented activities appropriately in process notes.
Participated in the Quality Assurance plan.
Complied with applicable CLIA and HIPAA regulations. ENROLLMENT SPECIALIST
Central Valley PACE, Stockton, CA /Oct 2020 – May 2021 As an Enrollment Specialist, oversaw the intake and enrollment process of new (PACE) Program of All-Inclusive Care for the Elderly participants.
Responsible for educating new potential participants and their caregivers on the benefits of Central Valley PACE Program.
Worked independently to gather information, setup appointments for assessments and document skills needs for incoming cases.
Interacted with family caregivers and participants.
Provided tours through PACE center, gathered crucial medical and social needs for new participants enrolled.
BENEFITS COORDINATOR
Stockton PACE, Stockton, CA /Oct 2018 – May 2020
Assisting prospective and enrolled participants in applying for benefits.
Resolving any eligibility issues with SSI, Medi-Cal (monitoring participants benefits status for application denials, eligibility discontinuances and annual redetermination dates.)
Medicare (managing part A and part B application during annual Medicare general enrollment period enabling a collection of additional capitations.)
Developed positive relationships with Medi-Cal, SSA, and DHCS staff to work proactively and collaboratively to resolve eligibility challenges.
Understanding of AEVS.
Collaborate with finance team to track revenue collection and projections to retroactive payments.
Develop positive rapport with participants and families.
Crosstrain on other marketing team roles and provide coverage as directed.
Submit enrollments to DHCS as participants enroll.
Run monthly reports for our partners and finance teams, monitoring of daily 834 report from DHCS.
ADMINISTRATIVE SUPPORT
Health Plan San Joaquin, San Joaquin, CA /Sept 2014 – May 2018
Administrative support for inpatient.
Concurrent Review: nurses consisting of calling hospitals for clinical reviews and/or discharge summary reports, which consists of daily collaboration with Out of Area Acute Care Facilities for up-to-date census.
Processing of all dis-enrollments for HPSJ which consists of gathering all pertinent information.
Determine whether members should be dis-enrolled either from LTC, or OOA, etc.
Evaluate patients on a case by case.
EDUCATION
International Business College, El Paso, Texas
Business Administration, 1980
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