Summary
Overview
Work History
Education
Skills
Accomplishments
Timeline
Generic

Brenda Guillen

Canoga Park,CA

Summary

Resourceful professional with over 13 years of expertise in case management and quality assurance within healthcare and legal sectors. Demonstrated capability to lead teams efficiently and surpass production targets through exceptional analytical skills. Dedicated to upholding high standards of professionalism and ethics in all interactions, prepared to embrace new challenges with a results-oriented mindset.

Overview

14
14
years of professional experience

Work History

Appeals Specialist-Medicare

Centene Management Company LLC
Woodland Hills, CA
04.2023 - Current
  • Ensured daily closure or triaging of all member or provider appeal requests, achieving expedited triage within one hour.
  • Participate in team meetings, adhering to updated policies for consistent compliance.
  • Review the validity of new incoming documents to prevent HIPAA violations, duplicates, misroutes, etc.
  • Documented case notes thoroughly, and drafted correspondence for mail or fax to maintain accurate records.
  • Conduct in-depth research to support case resolution decisions.
  • Met production goals by creating 20 cases each day.
  • Checked and responded to emails promptly to facilitate communication.
  • Led team training sessions, including new hire and cross-training initiatives.
  • Handled email escalations during the lead's absence to maintain workflow continuity.
  • Monitored team chats for escalations requiring an urgent response.
  • Collaborate with leadership to identify areas for improvement, and implement strategic changes.
  • Quality Assurance review and weekly audits of member work basket staff.
  • Assist with reporting needs and running reports on staff to ensure cases don’t go out of compliance, pending responses are addressed, and the workload is balanced.
  • Assisted with special projects as needed.

Grievance & Appeals Triage Coordinator I

Centene Management Company LLC
Woodland Hills, CA
07.2021 - 04.2023
  • Performed data entry to track and log member and provider appeals, in accordance with established regulatory and accreditation guidelines, and procedures.
  • Scrubbed member workbasket queue during high inventory to prevent compliance issues.
  • Validated all cases within 24 hours to ensure correct priority classification.
  • Triage or close all cases daily, maintaining quality and accuracy standards.
  • Provided weekend coverage for triage or intake tasks, as required.
  • Attended senior departmental meetings for knowledge sharing on procedural changes.
  • Supported intake processing in Faxcom and email queues to maintain workflow efficiency.
  • Achieved production metrics by generating a specified number of cases daily.
  • Checking and responding to emails daily.
  • Managed inbound and outbound calls, addressing inquiries and processing new case requests.
  • Documented case notes thoroughly, and drafted correspondence for mail to maintain accurate records.
  • Assisted in training new hires.

Grievance & Appeals Coordinator I

Health Net, LLC
Woodland Hills, CA
12.2019 - 07.2021
  • Reviewed and processed member and provider grievances and appeals per federal, state, and organizational regulations.
  • Prepared response letters addressing member and provider complaints, grievances, and appeals.
  • Ensured timely closure of all cases weekly, maintaining compliance with deadlines.
  • Optimized handling of state fair hearing requests, gathering documentation for successful outcomes.
  • Served as liaison between members, provider regulatory agencies, and internal staff to facilitate communication.
  • Reported verbal appeals and grievances to initiate case creation efficiently.
  • Assisted in monthly reconciliation reports, confirming data accuracy for operational integrity.
  • Manage large volumes of documents including copying, faxing and scanning incoming mail.
  • Participated in team meetings to adhere to updated policies and procedures.

Administrative Assistant I

Health Net, LLC
Woodland Hills, CA
08.2018 - 12.2019
  • Supported case coordinators and management in Appeals and Grievance Department operations.
  • Processed translation requests through a third-party vendor, ensuring timely delivery.
  • Monitored departmental voicemails and conducted necessary outbound calls for effective communication.
  • Collected and sorted incoming mail five times daily for accurate distribution.
  • Managed six fax queues, forwarding documents for appropriate handling.
  • Verified outgoing mail from Medicare teams using an online verification system.
  • Consistently met strict deadlines by completing daily tasks by end of day.

Legal Assistant

Gurovich Law Group, APC
Sherman Oaks, CA
05.2013 - 08.2018
  • Managed office operations and onboarding, ensuring seamles integration and efficiency.
  • Coordinated attorneys' schedules, including court dates, mediations, depositions, client appointments, DMV hearings, insurance statements.
  • Handled new client intake, fee agreements, and initiated new file procedures.
  • Organized case information, maintained accurate files, and assisted with discovery responses.
  • Filed documents with L.A. Superior Court.
  • Fostered strong relationships with court clerks, adjusters, appearance attorneys, clients, court reporters, and medical providers, facilitating smooth case progression and information exchange.
  • Handled property damage claims from start to finish, ensuring timely resolutions.
  • Assisted in various legal areas including personal injury, traffic, criminal defense, and employment law.
  • Arrange for service of process with attorney services and messenger services.
  • Translated legal documents and client communications, ensuring accuracy and clarity for Spanish-speaking clients.

Administrative Assistant / Account Executive

Wolf & Associates, LLC
Calabasas, CA
02.2011 - 11.2012
  • Provided crucial administrative support to executives, enhancing productivity at the office and Workers' Compensation Appeals Board.
  • Filed legal forms electronically using E.A.M.S., maintaining accuracy and compliance.
  • Drafted various legal documents, including notices of hearings, withdrawals of applications or liens, orders to remove off the calendar, and collection letters, enhancing case management.
  • Drove successful case closures through strategic negotiation, maintaining an up-to-date recovery list, and contributing to the firm's financial goals.
  • Facilitated smooth office operations through efficient supply management, mail distribution, and caller inquiry handling.
  • Managed confidential files, electronic records, and court board agendas, ensuring data integrity.
  • Compiled comprehensive exhibit packets for litigated cases, enhancing case preparation efficiency.

Education

Associate of Science - Paralegal Studies

ITT Technical Institute
Sylmar, CA
03.2013

Skills

  • Leadership and supervision
  • Microsoft Office proficiency
  • Fluent in Spanish
  • Typing speed 65 WPM
  • Case management expertise
  • Research capabilities
  • Medical terminology knowledge
  • Analytical skills
  • Written communication skills
  • Data entry accuracy
  • Outlook
  • Microsoft Teams collaboration
  • Software proficiency: Prime 20, OMNI, TruCare Cloud, Amisys Advanced v6, FileNet, CenPas, FaxCom, and Ember

Accomplishments

  • Nominee for our Medicare SuperSTAR recognition for the month of February, 2025. Recognized for exemplifying Centene’s core values of Curiosity and Service, consistently exceeding quality and production expectations. Proudly known to serve as a Lead Subject Matter Expert (SME), providing invaluable guidance to the team.

Timeline

Appeals Specialist-Medicare

Centene Management Company LLC
04.2023 - Current

Grievance & Appeals Triage Coordinator I

Centene Management Company LLC
07.2021 - 04.2023

Grievance & Appeals Coordinator I

Health Net, LLC
12.2019 - 07.2021

Administrative Assistant I

Health Net, LLC
08.2018 - 12.2019

Legal Assistant

Gurovich Law Group, APC
05.2013 - 08.2018

Administrative Assistant / Account Executive

Wolf & Associates, LLC
02.2011 - 11.2012

Associate of Science - Paralegal Studies

ITT Technical Institute

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