Skills
Work Availability
Work Preference
Summary
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Work History
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Education
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Overview
RegisteredNurse
Carla Gaona

Carla Gaona

Operations Support Senior Health Specialist
Dunedin,FL

Skills

  • Direct and Indirect Patient Care
  • Leadership
  • Operations and implementations
  • Project Management
  • Medical Billing
  • Medical Claims
  • Scheduling & Adherence
  • Insurance Verification
  • Medical Terminology
  • Electronic Medical Records
  • Medical Collections
  • Microsoft Office
  • Medical Administration
  • Medical Records
  • Medical Scheduling
  • Financial Services
  • Pharmacy Technician
  • Lean Six Sigma
  • SharePoint
  • Operational Efficiency
  • Customer Engagement
  • Workload prioritization
  • Operational Excellence
  • Reporting and documentation
  • Workflow Streamlining
  • Scheduling Coordination
  • Incident Management
  • Decision-Making
  • Team Collaboration
  • Task Prioritization
  • Team building
  • Relationship Building
  • Teamwork and Collaboration
  • Medical Records Management
  • Medical Office Management
  • Quality Assurance
  • Anatomy Knowledge
  • HIPAA
  • Medical Terminology
  • Medical and Pharmacy Prior Authorizations
  • Customer Service Production & Operations
  • Call Center Operations
  • PMB, Pharmacy Production Operations
  • Medical Claim Research and Operations
  • Medical and Pharmacy Insurance fields specializing in Medicaid, Medicare and commercial sectors
  • Patient Care Coordination and referrals
  • Medical chart prep & medical dictation review, comprehension & Interpretation
  • Office Management and Office Operations
  • Understanding of CMS, Medicare, and Medicaid billing guidelines
  • Knowledge of CPTS, ICD10, & HIPPA compliance
  • QNXT, Audit Logix, Epic, Trizetto, CareCloud, EClinical, PIMMS, EnCoderPro, ProPat, Salesforce, Variant, MedScript, CoreHub

Work Availability

monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Work Preference

Work Type

Full Time

Work Location

Remote

Important To Me

Career advancementWork-life balanceCompany CultureHealthcare benefitsWork from home optionPaid time off401k matchPaid sick leave

Summary

Team-oriented Operations Support Specialist with over 19 years of experience delivering operational analysis and technical and administrative support. Proactive self-starter excels at wide range of operational support, client and customer service deliverables. Dedicated to solving problems and meeting both complicated and mundane business needs with creative and team-oriented drive. Dedicated to increase client, team, patient, and provider satisfaction, retention, and growth by efficiently delivering competitive services to customers, clients, patients, and providers while maintaining a fully integrated and knowledgeable result with a customer focus supported by exemplary technologies and processes. ICare and ILead oriented leader with a patient first mentality.

Quote

“The supreme quality for leadership is unquestionably integrity. Without it, no real success is possible.”
President Dwight D Eisenhower

Work History

Operations Support Lead

McKesson / CoverMyMeds
Phoenix, AZ
10.2023 - Current
  • Provides support and coordination of workload distribution and advises other leadership of opportunistic advancements in service delivery, and quality while also identifying and escalating insufficiencies or improvements
  • Handles schedule adherence, program and system documentation, team development, training, and feedback on staff performance
  • Reinforces a culture of compliance for frontline staff applying and adhering to all government regulatory, antifraud, and abuse statutes
  • Supports other operation leadership with the departmental strategy to enhance customer experience, increase productivity, mitigate risk, improve processes, and increase employee, client, and customer satisfaction
  • Proudly supports and demonstrates McKesson's core values ICARE & ILEAD in all internal and external interactions.

Senior Health Specialist Case Account Management

Mckesson / Cover MyMeds
Scottsdale, AZ
03.2022 - Current
  • Educate and support doctors and staff on how to best leverage McKesson/ CoverMyMeds technology to reduce the burdens in the office and drive better outcomes for their patients
  • Utilize clinical knowledge to identify gaps in the patient care process, allowing for triage to the appropriate patient care services
  • Coordinate webinars and provide expert knowledge on how to use our software
  • Manage entire patient journey of medication access to ensure patients and their stakeholders are supported
  • Provide exceptional access and reimbursement support to doctors
  • Work with Health Care Offices, Field Representatives, Patients, Nurses, Specialty Pharmacies and Stakeholders to coordinate care and ensure alignment on patient and doctor needs or challenges
  • Experience handling advanced or escalated customer issues
  • Experience working patient case facilitation, in doctor's office settings and on behalf of a PBM or Specialty Pharmacies
  • Experience and understanding of the Prior Authorization processes
  • Relationship building with patients, providers, and clients
  • Excellent interpersonal communication skills
  • Positive attitude in challenging situations
  • Strong sense of empathy
  • Critical thinking skills
  • Demonstrated performance while prioritizing multiple tasks.

Health Service Specialist - Specialty Pharmacy Coordinator

Mckesson Corporation
Scottsdale, AZ
09.2019 - 03.2022
  • Responsible for providing telephonic patient counseling, nursing intervention with some support to physicians, and coordination and delivery of reimbursement and other services related to the patient support programs
  • Responsible for the coordination and delivery of services related to patient support programs
  • Involves interactions with patients, physicians, and other health care professionals, and members of a multidisciplinary team using web-based, telephonic, and face-to-face means of communication
  • Coordinate and track daily, weekly and monthly business goals and set tasks for the Indivior program
  • Management and processing of high-priority patient case file
  • High attention to detail with patient enrollment forms
  • Coordinate follow-ups with specialty pharmacies, physicians' offices and patients for coordination of care
  • Proactive outreach for referral confirmation
  • Provided accurate and timely follow-up to all pharmacy inquires
  • Communicated verbally and via email with the Specialty Pharmacies daily.

Care Coordinator III /Chart Prep/Office Administrator

Pueblo Family Physicians, LTD
Scottsdale, AZ
09.2018 - 09.2019
  • Obtained prior authorizations for specialists and radiology by completing the referral process, including medical records; submit for authorization; contact insurance company as needed for clarification of information
  • Submitted approved authorization to specialists' offices
  • Prioritize STAT referrals vs
  • Standard
  • Documented referral information
  • Assisted patients with specialist/radiology appointments; provided phone numbers and necessary information
  • Pulled charts for phone messages and faxes related to referrals
  • Set up home health care appointments
  • Returned patient and facility calls
  • Interacted with PFP Physician/Providers to insure proper instructions are given, Pulled charts for upcoming appointments
  • Prep each chart, read and interpret progress dictation, current patient demographics, and forms as required
  • Pulled same-day add-ons and prep in a timely manner
  • Filed all loose papers, mend old/torn charts, split charts
  • Call specialist offices to request records
  • Scanned, categorized, and implemented paper charts into the EMR system.

Medical Office Administration

Edicine Internal Medicine and Urgent Care
Scottsdale, AZ
02.2017 - 09.2018
  • As part of my day-to-day tasks in a face paced and busy medical office, I answered a multiple phone line system, scheduled appointments via implemented EMR programs and updated and organized patient charts and insurance information
  • Processed insurance forms, prepared reports, and assisted physicians with various medical administration duties
  • Using my knowledge of medical procedures and customer service, I recorded patient histories and schedule patients for hospitalization or other procedures
  • Prepared and followed referrals as well as prior authorizations
  • Other duties included bookkeeping tasks, such as billing patients, preparing financial and tax reports, and processing invoices AR/PR
  • Maintained and used spreadsheets, accounting, and word processing software, in addition to other office duties that included sending and receiving faxes of confidential medical information requests utilizing HIPAA laws and processes
  • I processed patient reports making sure they get to the correct department or physician
  • Used and maintained credit card payments POS for co-payments, deductibles, and cash-paying patients
  • I was also responsible for checking patients in at the front desk, Interviewing patients for case histories in advance of appointments, Compiling medical records and charts, processing insurance payments, and verifying insurance, policies co-payments, coinsurance, and deductibles
  • I also assisted medical billers in follow-ups and corrections on claim denials, AR, and payment postings.

Pre-Registration Patient Financial Counselor

Scottsdale Healthcare HonorHealth
Phoenix, AZ
01.2015 - 01.2017
  • Documented all facets of the registration process and meet accuracy goals as determined by management
  • Collected payments and meet regular collection targets as determined by management
  • Demonstrated the ability to collect payments, to resolve customer issues, and provide excellent customer service
  • Perform financial counseling when appropriate
  • Performs pre-registration/registration processes, verifies eligibility and obtains authorizations, submits notifications, and verifies authorizations for services
  • Verifies patients' demographics and accurately inputs this information into systems, including documenting the account thoroughly in order to maximize reimbursement and minimize denials/penalties from the payor(s)
  • Obtains federally/state required information and all consents and documentation required by the patient's insurance plans
  • Acted as a liaison between the patient, the billing department, vendors, physician offices, and the payor to enhance account receivables performance and meet payment collection goals, resolve outstanding issues and/or patient concerns, and maximize service excellence
  • Communicated with physicians, clinical and hospital staff, nursing, and Health Information Management Services to resolve outstanding issues and/or patient concerns
  • Work to meet the patient's needs in financial services.

Claims Analyst Claims Inquiry Research

Aetna
Phoenix, AZ
01.2012 - 01.2015
  • Answered questions, and resolve claim billing status and issues based on phone calls from providers, and plan sponsors
  • Provided exceptional customer service, claim research, and status utilizing Aetna's programs
  • Advanced in Medicare and Medicaid insurance billing, plan benefits, and medical claim coding
  • Exceptional ability and understanding of the claims process and procedures
  • Exceptional ability to negation and to build rapport with customers
  • Proficient with claim research and referrals, authorizations, new claim handoffs, nurse reviews, complaints with providers, grievances, and appeals via target systems
  • Educated providers on self-service options; assisted providers with credentialing and re-credentialing issues/and or transfer to appropriate departments
  • Responsible to determine medical necessity is required, applicable coverage provisions, and verifying member plan eligibility
  • Accurately performed in the review of member claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductibles
  • Performed data maintenance as necessary and used applicable system tools and resources for production and service requirements
  • Dedicated Mercy Care, Mercy Care Advantage, Mercy Maricopa Integrated, and Mercy Maricopa Advantage /SAMHSA plan specialist.

Pharmacy Tech/Technical Support Representative

MedImpact Healthcare Systems
Tempe, AZ
01.2011 - 12.2011
  • Assisted pharmacies with technical assistance in claim adjudication of RX claims, providing benefit coverage information, and assisting in obtaining prior authorizations for patients
  • Excelled in the PBM physician queue in a pharmacy call center setting and maintained company standards and regularly met performance standards
  • Assisted physician offices with policies and procedures in patient prescriptions benefit coverage, following benefit coverage guidelines
  • Regularly obtained and accurately documented medical information needed for approval of prior authorizations
  • Worked hand and hand with the prior authorization department to obtain and utilize benefits and clinical guidelines
  • Documentation included obtaining and understanding medical terminology and diagnosis codes and procedures
  • Assisted members with questions about their coverage.

Medical Records Management

Triwest Healthcare
Phoenix, AZ
01.2009 - 12.2010
  • Analyzed medical records of military personnel and their families
  • Attached and determined what approved insurance authorizations went to a claim, and attached the medical reports for approval and/or review
  • These reports included accurately reading and analyzing the patient's diagnosis, assessments, medical sig codes, CPT codes, rank, and area of service
  • Maintained contact with healthcare providers to retrieve and maintain the patient's information
  • Worked with the Department of Defense medical systems and insurance authorization systems
  • Performance was evaluated on a weekly and monthly basis.

Pharmacy Technician

CVS CareMark Mail Order Pharmacy
Phoenix, AZ
01.2006 - 12.2008
  • Assisted members, physicians, and insurance companies as well as internal departments in a PMB call center setting with order requests for prescribed medications
  • Accurately entered medications and counseled participants with questions about their medications and orders
  • Assisted pharmacists, physicians, and customer service representatives with processing issues
  • Upheld HIPAA and all state regulations
  • Answered a minimum of 15 calls per hour
  • Utilized all resources available to provide accurate and complete information.

Pharmacy Technician

Walgreens Central Pharmacy Operations
Tempe, AZ
01.2003 - 12.2005
  • Data entry of medical prescriptions which included medical sig codes, terminology, and days of supply, quantity, refill information, and doctor and patient information
  • Accurately entered all medical and personal information as well as calculated medications supplied to patients from healthcare providers
  • Maintained Walgreens standards for the central pharmacy operations procedures
  • Trained and certified by the Arizona Board of Pharmacy
  • Upheld all regulations of Arizona and other states mandated by federal laws
  • Maintained performance standards which included data entry of prescriptions within 52 seconds or less per script, an error rate of 3% or lower, and an average of 500 prescriptions filled per day
  • Performance standards evaluated weekly by team leads and pharmacists
  • Performance monitored on a daily basis
  • Upheld all performance standards with good to excellent quality.

Software

Corehub

Saleforce

QNXT

Verint

Tablu

Audit Logix

Epic

MedScript

Care Cloud

Microsoft Office

Education

Bachelors of Science in Medical Administration -

Grand Canyon University
07.2024

Arizona School of Business and Real Estate
04.2018

Reminton College
05.2004

Diploma in Education -

Gallup Central High School
05.2002

Timeline

Operations Support Lead

McKesson / CoverMyMeds
10.2023 - Current

Senior Health Specialist Case Account Management

Mckesson / Cover MyMeds
03.2022 - Current

Health Service Specialist - Specialty Pharmacy Coordinator

Mckesson Corporation
09.2019 - 03.2022

Care Coordinator III /Chart Prep/Office Administrator

Pueblo Family Physicians, LTD
09.2018 - 09.2019

Medical Office Administration

Edicine Internal Medicine and Urgent Care
02.2017 - 09.2018

Pre-Registration Patient Financial Counselor

Scottsdale Healthcare HonorHealth
01.2015 - 01.2017

Claims Analyst Claims Inquiry Research

Aetna
01.2012 - 01.2015

Pharmacy Tech/Technical Support Representative

MedImpact Healthcare Systems
01.2011 - 12.2011

Medical Records Management

Triwest Healthcare
01.2009 - 12.2010

Pharmacy Technician

CVS CareMark Mail Order Pharmacy
01.2006 - 12.2008

Pharmacy Technician

Walgreens Central Pharmacy Operations
01.2003 - 12.2005

Bachelors of Science in Medical Administration -

Grand Canyon University

Arizona School of Business and Real Estate

Reminton College

Diploma in Education -

Gallup Central High School

Personal Information

  • Relocation: Anywhere
  • Title: Healthcare Professional

Overview

22
22
years of professional experience

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Carla GaonaOperations Support Senior Health Specialist