Summary
Overview
Work History
Education
Skills
Timeline

Andrew Abiertas

Santa Ana,USA

Summary

I have many years of experience within the health care industry. I have worked multiple facets of medical insurance & dental insurance policies from coverage & eligibility verifications, to obtaining authorizations, & claims management. I have worked with patient & provider relations as well as billing for durable medical equipment. I am currently working in a Team Lead position for an employer under contract with Covered California to oversee workflow and employer & employee health plans for small businesses. I am however open to a career switch into IT and/or helpdesk applications, networking, wiring or the electrical trade. I have extensive knowledge in computers & other technology. Willing to relocate: Anywhere Authorized to work in the US for any employer

Overview

14
14
years of professional experience

Work History

CCSB Eligibility Team Lead

Pinnacle Claims Management
01.2025 - Current
  • Trained new team members by relaying information on company procedures and policy requirements.
  • Promoted a positive work environment by fostering teamwork, open communication, and employee recognition initiatives.
  • Served as a role model for the team by demonstrating commitment to excellence, professionalism, and adherence to company values at all times.
  • Coached team members in techniques necessary to complete job tasks.
  • Analyze & manage workflow process.
  • Established open and professional relationships with team members to achieve quick resolutions for various issues.
  • Evaluated staff performance and provided coaching to address inefficiencies.
  • Devised and implemented processes and procedures to streamline operations.

Covered California Small Business Eligibility Specialist III

Pinnacle Claims Management
07.2023 - 01.2025
  • Conduct training for my peers & new hires.
  • Create training operating procedures documentation or update existing.
  • Manage Covered California Medical & Dental insurance policies for Small Business Employers & their employees.
  • Analyze & Report peer workloads, adjust as-needed.
  • Assist in high volume processing of EDI enrollment transactions which include adds, changes, and terminations for employees (EE) and employers (ER) within HCPs, NFP & Salesforce work environments.
  • Assist with coverage verification ticket processing and inquiries as well as agent of record, book of business transfers.
  • Recognize and research exception & NFP ticket protocols.
  • Effectively communicate with customers, brokers, agents and authorized contacts while maintaining professionalism and proper verbiage.
  • Recognize a multitude of processing time windows and guidelines for enrollment requests.
  • Maintaining a HIPAA compliant workspace.
  • Understand and follow oral and written directions.

CCSB Eligibility Specialist II

Pinnacle Claims Management
05.2022 - 05.2023
  • Enhanced client satisfaction by providing timely and accurate eligibility determination for various assistance programs.
  • Reduced errors in eligibility determinations by maintaining thorough knowledge of program guidelines and regulations.
  • Provided exceptional customer service through prompt response times, clear communication channels, and diligent follow-up practices.
  • Ensured compliance with local, state, and federal regulations during all phases of the eligibility determination process.

CCSB Eligibility Specialist I (Temp to Hire)

Kforce Professional Staffing & Solutions
06.2021 - 05.2022
  • Assist in high volume processing of EDI enrollment transactions which include adds, changes, and terminations for employees (EE) and employers (ER) within HCPs, NFP & Salesforce work environments.
  • Assist with coverage verification ticket processing and inquiries as well as agent of record, book of business transfers.
  • Recognize and research exception & NFP ticket protocols.
  • Effectively communicate with customers, brokers, agents and authorized contacts while maintaining professionalism and proper verbiage.
  • Recognize a multitude of processing time windows and guidelines for enrollment requests.
  • Maintaining a HIPAA compliant workspace.
  • Understand and follow oral and written directions.

Customer Service Representative (Medi-cal)

Caloptima
10.2020 - 05.2021
  • Establish and maintain effective interpersonal relationships with members, coworkers and the public.
  • Function efficiently and productively in a high-volume telephone call center.
  • Effectively communicate both in writing and verbally.
  • Learn procedures and regulations governing member eligibility and the terminology and documents used while remaining knowledgeable of CalOptima/Medi-Cal benefits and procedures.
  • Understand and follow oral and written directions.
  • Hear and speak well enough to converse on the telephone and in person.
  • Perform work requiring repetitive use of hands, arms or shoulders (e.g. keyboarding, typing, etc.).
  • Effectively utilize computer and appropriate software and interact as needed with CalOptima Information Systems.

Customer Service Representative

Allswell
08.2020 - 10.2020
  • Temp-to-Hire for Caloptima Customer Service position.
  • Establish and maintain effective interpersonal relationships with members, coworkers and the public.
  • Function efficiently and productively in a high-volume telephone call center.
  • Effectively communicate both in writing and verbally.
  • Learn procedures and regulations governing member eligibility and the terminology and documents used while remaining knowledgeable of CalOptima/Medi-Cal benefits and procedures.
  • Understand and follow oral and written directions.
  • Hear and speak well enough to converse on the telephone and in person.
  • Perform work requiring repetitive use of hands, arms or shoulders (e.g. keyboarding, typing, etc.).
  • Effectively utilize computer and appropriate software and interact as needed with CalOptima Information Systems.

Scheduling Specialist

Restore Motion
05.2017 - 08.2020
  • Schedule & coordinate multiple field technicians to service post-operative medical equipment and bracing to orthopedic surgical patients in a timely & heavy logistical manner. Whether at home, hospital or surgery center in the Los Angeles area & outlying counties.
  • Contact patients to relay the importance of the prescribed orthopedic equipment as well as the individual protocols assigned by our expansive number of orthopedic surgeons from high value accounts.
  • Communicate with orthopedic center staff or hospital staff to assist with providing proper care to their patients.
  • Confirm with the technicians & patients that proper payment & documentation has been obtained to bill insurance.
  • Occasional troubleshooting of equipment.

Customer Quality Specialist

Apria Healthcare
02.2014 - 05.2017
  • Verifying a wide range patient insurance information including but not limited to: Medicare, HMO & PPO plans for accuracy and reimbursement of various durable medical equipment & services provided by Apria.
  • Communicate with patients, physicians, and case/discharge managers to request documentation, collect co-pays, and arrange deliveries in a timely manner.
  • DQP certified with Medicare for oxygen.

Senior Customer Service Specialist

Apria Healthcare
10.2012 - 01.2014
  • Coordinates with other branches within the country to provide patients with almost all types of medical equipment the company provides ie: Oxygen setups, Cpap supplies, Wheelchairs etc. for travel.
  • Provides a respiratory plan of care to many patients who travel through-out the country whether by car, train, vacation cruise or aircraft while complying to each unique company/environment guidelines.
  • Heavily utilizes MS Word, Excel, and Outlook to organize and coordinate extremely time sensitive trips/orders.
  • Builds strong rapport with recurring patients to insure customer loyalty for future travels.
  • Maintains professionalism when communicating internally and externally through-out the company.
  • (949) 614-7845

Customer Service Specialist

Apria Healthcare
08.2011 - 10.2012
  • Responds to telephone, fax and EDI inquiries and orders from referral sources and homecare patients
  • Documents referral requests for coordination of care
  • Demonstrates professional etiquette and courtesy when interfacing with customers
  • Resolves patient/customer complaints by identifying problems and coordinating appropriate corrective action
  • Assesses patient needs as well as promoting company products and services
  • Complies with and adheres to all regulatory compliance area, policies, procedures and "best practices"

Fax intake - Apria Healthcare Temp

CORESTAFF Services
04.2011 - 08.2011
  • Received high volume of inbound orders for DME via fax intakes which included authorizations, prescriptions, and referrals etc.
  • Performed large volume data entry of customer demographics, diagnosis, physician, insurance information.
  • Required attention to detail and accuracy inputting time sensitive medical information within company systems.
  • Hired on permanently after being recognized for high order output.

Education

High school or equivalent - General Ed

Saddleback Community College, Mission Viejo, CA
05.2008

Skills

  • Strong data entry skills with emphasis on speed and accuracy
  • Ability to adapt quickly to new company practices/procedures
  • Time Management
  • Strong inter-personal skills
  • 10 years in clerical environment
  • 10 years Healthcare
  • Proficient knowledge of office applications (MS Word, Excel & Outlook)
  • Proficient knowledge of OS/Web based applications (Win 10, Firefox, Chrome) as well as the ability to learn & utilize customized company software
  • WPM 80/KPH 10K while maintaining accuracy
  • Microsoft Outlook
  • Scheduling, Logistics & Time Management
  • Coaching and mentoring
  • Conflict resolution
  • Performance monitoring

Timeline

CCSB Eligibility Team Lead - Pinnacle Claims Management
01.2025 - Current
Covered California Small Business Eligibility Specialist III - Pinnacle Claims Management
07.2023 - 01.2025
CCSB Eligibility Specialist II - Pinnacle Claims Management
05.2022 - 05.2023
CCSB Eligibility Specialist I (Temp to Hire) - Kforce Professional Staffing & Solutions
06.2021 - 05.2022
Customer Service Representative (Medi-cal) - Caloptima
10.2020 - 05.2021
Customer Service Representative - Allswell
08.2020 - 10.2020
Scheduling Specialist - Restore Motion
05.2017 - 08.2020
Customer Quality Specialist - Apria Healthcare
02.2014 - 05.2017
Senior Customer Service Specialist - Apria Healthcare
10.2012 - 01.2014
Customer Service Specialist - Apria Healthcare
08.2011 - 10.2012
Fax intake - Apria Healthcare Temp - CORESTAFF Services
04.2011 - 08.2011
Saddleback Community College - High school or equivalent, General Ed

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Andrew Abiertas