Baylee Dominguez
Glendale,CA
Summary
Detail-oriented individual with solid background in managing complex caseloads and coordinating services to meet member needs. Proven ability to handle multiple tasks effectively and efficiently in fast-paced environments. Recognized for taking proactive approach to identifying and addressing issues, with focus on optimizing processes and supporting team objectives.
Overview
4
4
years of professional experience
Work History
Grievance & Appeals Case Coordinator I
Health Care Support & Centene
06.2022 - Current
- Investigated complex member grievances and appeals regarding service quality, claim disputes, navigating regulatory requirements facilitating prompt resolutions that improved client satisfaction scores by enhancing response times to inquiries by eight days on average
- Verifies member insurance coverage and/or service/benefit eligibility via system tools
- Prepare files for clinician review while utilizing an Electronic Medical Records (EMR) system
- Supports the authorization/clinical review process by researching and documenting necessary medical information such as history, diagnosis, and prognosis based on the referral to the clinical reviewer for determination
- Able to work 40+ case load for HMO, PPO, POS, and Medi-Cal plans, which can vary from quality-of-service grievances, concurrent quality of care grievances, retrospective quality of care grievances, pre-service and post-service clinical and standard appeals
Medical Billing Specialist
Mini Pharmacy Enterprises, Inc
01.2022 - 05.2022
- Exhibits the ability to prioritize, multi-task and meet daily productivity and month-end closing deadlines
- Understands eligibility, benefits, authorization verification for treatments, complex payer contract terms, and fee schedule for all payers
- Ensures accuracy and appropriateness of claim type, diagnosis codes, place of service, procedure codes, proper use of modifiers, as defined by government payers and contracted plans
- Coordinated with healthcare providers, insurance companies, and patients to verify and secure pre-authorization for durable medical equipment (DME) supplies
- Utilized knowledge of medical terminology, coding systems, and insurance policies to accurately assess and process authorization requests.
Medical Billing & Coding Externship
Mini Pharmacy Enterprises, Inc
11.2021 - 12.2021
- Review delinquent accounts and call the responsible party(ies) for collection purposes
- Calls to verify insurance and billing information with physicians and following up with doctors on any missing information such as time spent
- Answers telephone inquiries and maintains a professional level of telephone etiquette
- Actively communicates status of assigned work, escalated billing concerns and challenges that could affect claims submission and processing with the Supervisor/Manager
Case Manager I
Telecare Corporation
10.2020 - 04.2021
- Update case files to consistently maintain accurate records
- Set up doctor appointments and check health insurance status/benefits
- Help clients enroll in SSI disability due to no or low income
- Facilitate training and counseling sessions for all clients
- Manage over 120 cases at any given time
- Conduct home visits and schedule follow-up appointments
Education
Medical Billing and Coding Program -
American Career College
Los Angeles, CA11.2021
Bachelor of Arts - Psychology
California State University, Dominguez Hills
Carson, CA12.2019
Skills
- Customer Service
- Scheduling
- Time Management
- HIPPA
- Outlook
- DOFR/PSAS
- Insurance Verification and Data Entry
- Medical Research and Documentation
- Authorization and Referral Management
- Eligibility/Intake
- Denials/Appeals
- HMO/PPO/ POS/Medi-Cal
- ICD-10/CPT/HCPCS
- 60 WPM & 10 Key
- CMS 1500 & UB-04
- Microsoft Office/PowerPoint/Excel
- Strong oral skills, written skills, and problem-solving skills
Timeline
Grievance & Appeals Case Coordinator I
Health Care Support & Centene
06.2022 - Current
Medical Billing Specialist
Mini Pharmacy Enterprises, Inc
01.2022 - 05.2022
Medical Billing & Coding Externship
Mini Pharmacy Enterprises, Inc
11.2021 - 12.2021
Case Manager I
Telecare Corporation
10.2020 - 04.2021
Bachelor of Arts - Psychology
California State University, Dominguez Hills
Medical Billing and Coding Program -
American Career College
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