Summary
Overview
Work History
Education
Skills
Timeline
Generic

Angeles rojas

Hialeah Gardens,United States

Summary

Seasoned professional with over 12 years of expertise in Medicare and Medicaid services, notably with Anthem Inc. Demonstrates advanced knowledge of CMS regulations and adept at claims resolution. Excels in analyzing needs and delivering solutions, blending technical proficiency with exceptional communication skills to enhance customer satisfaction and compliance standards.

Overview

18
18
years of professional experience

Work History

Member and Provider Service II

Anthem Inc.
Miami, FL
01.2020 - Current
  • Provide clear explanations of benefits, eligibility requirements, and applicable laws when communicating with Medicaid, Long Term Care, and Florida Healthy Kids members.
  • Respond to customers' and providers' inquiries via telephone and written correspondence regarding insurance benefits, eligibility, authorizations, appeals, claims, and general provider contracts.

  • Maintain detailed records of all communication with customers, claimants, providers, internal departments, and outside vendors.
  • Use the company troubleshooting resolution tree to evaluate technical problems, while leveraging personal expertise to find appropriate solutions.
  • Review and verify claim information to ensure the accuracy of data, and compliance with established policies.

Medicare Sales Agent

Humana Inc
Miramar, FL
07.2006 - 08.2018
  • Performed a needs analysis to obtain the information required to make appropriate health insurance product recommendations.
  • Served as a subject matter expert by effectively presenting information and responding to questions from CMS star rating.
  • Exhibited proficiency in executing software programs specific to PDP and MAPD plans.
  • Delivered subject matter expertise for internal and external customers on compliance best practices, and quality control.
  • Verified insurance coverage by telephone and online to guarantee proper reimbursement of benefits and estimate patients' financial responsibilities.
  • 12 years of account management experience by providing customer support, improving opportunities to increase product and service consumption with MAPD, and PDP.

Education

Bachelor of Science - Health Care Administration

University of Central Florida
Orlando, FL
08-2022

Skills

  • 12 years of Medicare (MAPD, PDP, and Medicare Supplement) and Medicaid experience
  • Advance knowledge of Medicare, Medicaid, Long Term Care claims, benefits, authorization, grievance and appeals processing
  • Advance knowledge of of CMS rules and regulations
  • Advance knowledge of federal, state, and local regulations
  • Knowledge of ICD coding
  • Understanding managed care contracts, including contract language, and reimbursement
  • Comprehensive knowledge of claims systems, adjudication, submission processes, coding, and/or dispute resolution

Timeline

Member and Provider Service II

Anthem Inc.
01.2020 - Current

Medicare Sales Agent

Humana Inc
07.2006 - 08.2018

Bachelor of Science - Health Care Administration

University of Central Florida

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Angeles rojas