Annelis Ortiz
Orlando
Overview
9
9
years of professional experience
Work History
Appeals and Grievances Specialist
Humana Remote
12.2022 - 07.2024
- Assists members, via phone or mail further/support quality related goals
- Investigates and resolves member and practitioner issues
- Decisions are typically focus on methods, tactics, and processes for completing administrative tasks/ projects
- Regularly exercises discretion and judgement in prioritizing requests and interpreting and adapting procedures, processes and techniques and works under limited guidance due to previous experiences/ breadth and depth of knowledge of administrative processes and organizational knowledge.
Insurance Verification Specialist
Orlando Family Physicians
06.2021 - 10.2022
- Verify health insurance of patients before having appointment with primary doctor
- Check deductibles, copays and/or coinsurances
- Apply correct primary physician
- Receive payments to the insurance balance through incoming calls
- Sending emails and faxes.
Claims Examiner
Molina Healthcare of Puerto Rico
02.2015 - 03.2021
- Analyze complaints received for the government health system
- Award payments or denials according to established procedures
- Validate information on documents, eligibility dates or contracts of suppliers with the corresponding departments
- Analyze corrected claims sent by suppliers and process them
- Process claims from Molina Healthcare Ohio, Michigan, Texas, Illinois, New Mexico, Wisconsin or Washington
- Work claims with high aging according to the procedures established by the department
- Apply rules established by state for the claims process
- Work mental health claims by applying the rules by state.
Education
BA Degree - Communications
Bayamon Central University
01.2006
Skills
- Dynamic, Responsible, Excellent communication skills Ability to work with the public and work in a team Ability to work under pressure and minimum supervision Strong sense of punctuality, responsibility and compliance
Workschedule
Full-Time
Programming
Microsoft Office, Word, Power Point, Excel
Applications
PMHS, QNXT, MC21, Abarca, Health suite, CCMS, Meditis
Platforms
Workflow, Claim Viewer+ ECW and 11E, Availity Insurances portals, CAS, EHUB, Mdhok
Availability
Job Type: Permanent
References
Available upon request
Languages
Spanish
Native or Bilingual
English
Professional Working
Timeline
Appeals and Grievances Specialist
Humana Remote
12.2022 - 07.2024
Insurance Verification Specialist
Orlando Family Physicians
06.2021 - 10.2022
Claims Examiner
Molina Healthcare of Puerto Rico
02.2015 - 03.2021
BA Degree - Communications
Bayamon Central University
Similar Profiles
ROCHELLE FOLEYROCHELLE FOLEY
Over Viewer at Humana RemoteOver Viewer at Humana Remote
Keasia WatkinsKeasia Watkins
Healthcare Customer Service Representative at Humana- RemoteHealthcare Customer Service Representative at Humana- Remote
LaQuawn JonesLaQuawn Jones
Inbound Contact Representative 1 at Humana- RemoteInbound Contact Representative 1 at Humana- Remote
Zaely ZorrillaZaely Zorrilla
EMS Supply & Equipment Coordinator at City of OrlandoEMS Supply & Equipment Coordinator at City of Orlando
Jean-Marc Rivera CabanJean-Marc Rivera Caban
Field Sales Representative at Erie HomeField Sales Representative at Erie Home