Care Management Medi-Cal
Resume:
Ecatarina Aguila
South Gate, CA 90280
Cell Phone: 626-***-****
Email: ***************@*****.***
Summary of Skills
• Over 3 years of experience in healthcare services specializing in insurance verification, authorization coordination and billing
• Strong knowledge of insurance eligibility via online portals and phone for HMO, PPO, Commercial, Medicare and Medi-Cal
• Bilingual: English and Spanish
• Software: Cerner, NextGen, I2I, GE-Centricity, GECB, KCPA, EYEMD,. OTTER, PBAR, Mosaiq, Salesforce (CRM), AEOS, Power Chart, Microsoft Office Suite-2010-2013-Office 365 (Excel,
Word, PowerPoint, Outlook)
Remote Bilingual Care Navigator
SCAN HEALTH PLAN (Temp) Tek Systems - Long Beach, CA
AEP: 2024 November 2024- May 09, 2025
AEP: 2023 October 2023-March 2024
• Conducts telephonic outreach to SNP members to perform initial and annual health screenings, also known as Health Risk Assessments (HRAs).
• Documents HRA information in the care management system during the phone call with the member and/or caregiver and documents all corresponding information or notes per department policy.
• Makes outbound calls to members based on identified health interventions or quality initiatives. Encourages provides assistance to members who may encounter obstacles to seeking care.
• Uses pre-defined criteria to refer cases to care coordination and/or care management based on HRA responses.
• Referrals made to internal resources or Provider Organization Care Management Programs as needed. • Collaborates with Provider Organizations to gather SNP eligibility verification and documents in the case management system.
• Coordinates continuity of care issues with SCAN contracted Provider Organizations to ensure existing services/supplies are authorized for newly enrolled members. • Utilizes department desktop procedures, workflows, job aids and training material. Identifies barriers to work processes and brings to the attention of the supervisor/manager.
• Maintains the member‘s right to privacy and protects SCAN operations by keeping information confidential.
• Adheres to all quality, compliance and regulatory standards to achieve HCS and SCAN outcomes.
• Actively supports the achievement of SCAN’s Vision and Goals.
• Contributes to team effort by accomplishing related results as needed.
November 2022 – 08/01/2023
South Central Family Health Centers
Referral Case Specialist
• Responsible for reviewing the authorization queue for applicable orders
• Verified and complied with payer contractual authorization requirements
• Submitted authorization request timely and efficiently, ensuring proper documentation is included for review, utilizing website portal and electronic options to submit requests
• Communicated with patients and referring physicians to obtain medical records, correct insurance and benefit information
• Processed prior authorizations for patient visits, treatments, and other procedures
• Working knowledge of third party payor verification terminology to determine benefit eligibility and interpretation of coverage: HMO, PPO, Commercial, Medicare, Medi-Cal
• Knowledge of State and Federal programs to ensure reimbursement from Medicare,
Medi-Cal, or other sponsoring agencies.
• Extensive knowledge of ICD9 and CPT codes
Professional Experience
April 2020 to August 2022
California Hospital Dignity Health
Patient Access Representative- Emergency Room
Responsible for checking in patients.
Making sure all information is entered correctly in the system.
Verifying insurance and collecting ER copayments.
When a Trauma comes in, we are hands on with the police to gather all information that is needed for all trauma forms.
Providing patients with temporary Medical.
Extensive knowledge of ICD9 and CPT codes
Securing all inpatient authorizations
Bed board Control
Professional Experience
October 2018-March 2020
Adventist Health White Memorial
October 2018-March 2020
Insurance Verifier - Pre- Services for Surgeries (Kforce)
• Responsible for reviewing the authorization and making sure all physicians orders are scanned in as well as an authorization.
• Create patient estimates with a break down of all charges and including any OOP, deductibles and co-insurances.
• Communicated with patients and referring physicians to obtain medical records, correct insurance and benefit information
• Working knowledge of third party payor verification terminology to determine benefit eligibility and interpretation of coverage: HMO, PPO, Commercial, Medicare, Medi-Cal
• Knowledge of State and Federal programs to ensure reimbursement from Medicare, Medi-Cal, or other sponsoring agencies. As well as submitting SAR request for any item patient might need.
• Assisted billing team to resolve insurance denials as they relate to authorizations & insurance verification
• Ability to interpret and understand various medical insurance plans and make accurate determinations regarding coverage
• Extensive knowledge of ICD9 and CPT codes
Professional Experience
USC Keck School of Medicine
Referral Case Specialist
April 2017 – June 2018
Authorization Coordinator (Kforce)
• Responsible for reviewing the authorization queue for applicable orders
• Verified and complied with payer contractual authorization requirements
• Submitted authorization request timely and efficiently, ensuring proper documentation is included for review, utilizing website portal and electronic options to submit requests
• Communicated with patients and referring physicians to obtain medical records, correct insurance and benefit information
• Processed prior authorizations for patient visits, treatments, and other procedures
• Working knowledge of third party payor verification terminology to determine benefit eligibility and interpretation of coverage: HMO, PPO, Commercial, Medicare, Medi-Cal
• Knowledge of State and Federal programs to ensure reimbursement from Medicare, Medi-Cal, or other sponsoring agencies
• Assisted billing team to resolve insurance denials as they relate to authorizations
• Ability to interpret and understand various medical insurance plans and make accurate determinations regarding coverage
• Extensive knowledge of ICD9 and CPT codes
Professional Experience
Convalo Health International/Blvd. Treatment Centers
Insurance Verifier
August 2016 – October 2016
Verification Benefits Specialist for Detox
• Responsible for the pre-verification for clients being admitted to treatment center
• Provided professional, accurate, timely insurance verification and notification for Detox, Residential, and Partial Hospitalization and IOP levels of care
• Verified all demographic and insurance information is complete/correct and obtained any missing information
• Understanding of medical coding and experience with utilization review
• Utilization of various electronic verification systems; UHC Online, Naviant, Provider Express, Availity for benefit eligibility as well as by phone for accuracy
• Verified and documented in CRM clients co-pay, co-insurance, deductible and out of pocket
Professional Experience
Glendale Adventist Medical Center – Adventist Health
May 2016 – August 2016
Hospital Biller & Collector (Contract)
• Ensured all Outpatient hospital/Surgery Center billing and coding were accurate
• Reviewed coding information about diagnosis on charge and procedures performed, corrected claim errors and rejections
• Responsible for all professional claim collections, appealing and reviewing of denied and unpaid claims
• Verified patients’ insurance coverage
• Collected on delinquent accounts by establishing payment arrangements with patients; monitoring payments; following up with patients when payment lapses occurred
• Researched all information needed to complete billing process among which are information from physicians and providers
Professional Experience
Grand Avenue Imaging
Insurance Verifier
January 2016 – March 2016
Front Office Administrator & Patient Care Coordinator
• Promptly answered and triaged incoming hotline calls, reviewed new patient cases in the database system using the information submitted on the portal
• Verified patient demographics, insurance details, and ensured caregiver contacts
• Completed all enrollment activities including providing an acknowledgment notice to the referring party via the departmental approved method
• Followed all program Standard Operating Procedures
• Assisted Case Manager with the coordination and logistics of the product and ancillary supplies needed for treatment, documenting all communication during the process
• Served as a resource for coordinators, to assist with problem-solving and implementation of streamlined workflows which includes scheduling appointments, documenting clinical interactions, company metric reporting, and managing individual workloads/capacities
• Organized team meetings and manages interpersonal relationships to support strong
Professional Experience
Beverly Hills Cancer Center & Optima Diagnostic Imaging
Referral Case Specialist
September 2015 – December 2015
Oncology Billing & Authorization Representative (Intern)
• Researched information, depending on type of out-of-network specialty care requested, to find similar specialists who are contracted with the member’s plan
• Coordinated scheduling with participating specialists to facilitate timeliness of care
• Communicates effectively with all parties (members, providers, vendors, facilities and other staff members)
• Responsible for timely outpatient and inpatient authorization review for completeness and entry via fax, authorization necessity [utilizing the authorization grid], member eligibility, Other Health Insurance, Third Party Liability, Member Flags, new member continuity of care, provider network status, member drive time, retroactive authorization processing, need for medical necessity review [utilizing the list of services that require medical necessity review], and benefit coverage
• Placed outbound calls to facilities or providers for clinical information for medical necessity reviews [utilizing checklists for documentation required for each service on the list of services requiring medical necessity review] or authorization clarity
• Enters routine and select non-routine authorizations into our care management system and approves or pends referral management process including home health, chemotherapy, rehab, home Infusion, observation and emergency requests
• Complied with all contract requirements and organizational and/or department standards for the processing and management of authorizations
Black Halo Clothing
June 2011 – October 2012
Customer Service Representative
• Processed Orders, data entry & processed invoices
• EDI & GXS Catalog maintenance
• Processed FedEx and UPS shipments worldwide
• Handled major stores routing & shipping compliance
• Reviewed all orders prior to processing, including emailed orders, WEB and APP orders
Education
American Career College
Medical Billing Coding Certificate
Roosevelt High School
Diploma
Commendations:
City of Alhambra for Outstanding Patient Service (USC) - 2017
US Senate Commendation for USC Patient Care - 2017
City of Glendale for Patient Care – 2016
City of Los Angeles Mayor Commendation for Patient Service - 2016
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