Clinical Operations Assistant II with expertise in insurance verification and patient registration. Proven track record in enhancing communication and resolving complex issues for efficient case processing. Strong-problem solving and detail-oriented skills improve workflow management, contributing positively to patient outcomes.
Overview
23
23
years of professional experience
1
1
Certification
Work History
Clinical Operations Assistant II
Gold Coast Health Plan
Camarillo, CA
01.2013 - Current
Enhanced communication between members, providers, and facilities, ensuring smooth information flow.
Assisted department manager with planning of routine operations and special projects.
Requested clinical information from facilities to ensure timely case completion.
Collaborated with multiple departments to ensure seamless authorization process and services.
Assisted in resolving provider disputes by coordinating with nursing staff and managing case creation.
Generated and dispatched denial notices to facilities due to insufficient information.
Conducted outreach to hospitals and providers for necessary clinical information.
Verified benefits and eligibility based on Gold Coast contracts guidelines and, HIPAA regulations.
Researched pending pre-authorization cases and resolved associated issues.
Coordinated the authorization process and services to members and providers in a timely manner.
Provided administrative support to the nurses, and department lead by reviewing documents and processing them for authorization.
Front Office Registration Clerk/Medical Assistant/Referrals Department
Sierra Vista Family Medical Clinic
Simi Valley
03.2010 - 02.2013
Assisted with scheduling appointments based on provider availability. Processed patient registration forms, collected fees, and issued receipts for services rendered. Verified insurance coverage and eligibility for services.
Reviewed patient medical records and verified accuracy of information in the system.
Processed referrals to in-network and out-of-network providers, followed up with authorizations and denials, researched in-network and out-of-network providers, scheduled appointments, and reached out to members with appointment instructions.
Assisted members with approvals for special health care programs available according to guidelines. Assisted the Urgent Care Center as a medical assistant as needed, called in RXs, informed patients of procedure/lab work results, and instructed them per doctors' orders.
Interpreted for doctors as needed, and assisted with in-office procedures.
Performed data entry tasks to update patient information in the system.
Maintained confidentiality of all patient records according to HIPAA regulations.
Customer Service Representative
Foundation for Medical Care of Santa Barbara and Kern County
Bakersfield
07.2009 - 02.2010
Received and processed over 100 calls on a daily basis
Obtained initial information from providers and members to begin Appeals, Grievances, and Out of Network requests. Research member and provider claims issues
Updated coordination of Benefits in system for Foundation, Prudent Buyer, and Medicare Policies.
Quote in and out of network benefits to Members and Providers on Foundation and Prudent Buyer Policies for in and outpatient surgeries, Skilled Nursing services, Home Health, Home Infusion, Physical, Occupational, Speech, Chiropractic Services, Acupuncture Therapy, Durable Medical Equipment, Hearing Aids, Office Visits, Routine Physicals, Immunizations, Injectable, Chemo, Radiation, and Transplants
Sr. Provider Relations Representative
WellPoint / Anthem BlueCross of California
Newbury Park
04.2002 - 06.2009
Provide a line of communication between the medical community, subscribers, members, WellPoint clients and the company
Responded to calls from all parties relating to contract administration, pre-authorization and benefit clarification
Analyzed problems and provides information/solutions or direction to appropriate resource person
Developed and maintained positive customer relations
Built cases for HMO, PPO, Skilled Nursing Facilities, Hospice, Home Infusion Services (HIT), Home Health Agencies (HHA), In-Patient Acute Rehab, Physical Therapy, Occupational Therapy, Chiropractic Therapy, Durable Medical Equipment (DME), and Speech Therapy
Create intakes for CalPERS Department
Received and processed 100 to 150 calls on a daily basis
Built cases for cosmetic procedures such as Breast Augmentation, Tummy Tuck, Mandibular Surgeries, Blepharoplasty etc…
Education
Associates Degree - General Studies-Social and Behavioral Sciences
Ventura Community College
Ventura, CA
Associates Degree - Science
Ventura Community College
Ventura, IA
Associates Degree - Administration of Justice
Ventura Community College
Ventura
Medical Terminology Certificate - Nursing Education
Visalia Adult School
Visalia, CA
High School Diploma -
Reedley High School
Reedley
Criminal Justice - Sociology
Ventura College
Ventura, CA
Skills
Advanced insurance verification
Efficient patient registration
Strong medical records management
Effective communication and teamwork
Precise data entry accuracy
Strong customer service
Referral processing
Efficient workflow management
Experience with Outlook, Teams, MS, Excel, EMR, Cerner, True Care, and Medical Eligibility Website
Medical terminology
Knowledge of benefits and contract information
Knowledge of provider NPI and TAX id numbers
Knowledge of group policies PPO,HMO,Medical/Medicaid/ Commercial,Fee For Service and others
Knowledge of CPT and HCPCS codes
Knowledge of ICD-10 diagnosis
Knowledge of Skilled Nursing Facilities
Knowledge of inpatient and outpatient rehab services
Knowledge of CCS and Case Management referrals
Ability to learn new procedures quickly
Certification
Associates Degree in Arts General Studies-Social and Behavioral Sciences
Associates Degree in Science
Associate Degree in Administration of Justice
Criminal Justice Certificate
Medical Assistant and Medical Terminology Certificates
High School Diploma
Languages
Spanish
Professional
Timeline
Clinical Operations Assistant II
Gold Coast Health Plan
01.2013 - Current
Front Office Registration Clerk/Medical Assistant/Referrals Department
Sierra Vista Family Medical Clinic
03.2010 - 02.2013
Customer Service Representative
Foundation for Medical Care of Santa Barbara and Kern County
07.2009 - 02.2010
Sr. Provider Relations Representative
WellPoint / Anthem BlueCross of California
04.2002 - 06.2009
Associates Degree - General Studies-Social and Behavioral Sciences
Ventura Community College
Associates Degree - Science
Ventura Community College
Associates Degree - Administration of Justice
Ventura Community College
Medical Terminology Certificate - Nursing Education