Summary
Overview
Work History
Education
Skills
Certification
Languages
Timeline
Generic

Angelica Andrade

Fillmore,CA

Summary

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

Visalia Adult School

High School Diploma -

Reedley High School

Criminal Justice - Sociology

Ventura College
Angelica Andrade