Carlos RAMIREZ
Rancho Cucamonga,CA
Summary
Highly motivated Case Coordinator with over 12 years of experience in Kaiser Permanente's Occupational Medicine Department. Energetic and reliable with extensive interviewing and researching knowledge. Superb clinical reasoning and decision-making talents.
Overview
20
20
years of professional experience
Work History
Case Coordinator
Kaiser Permanente
03.2013 - Current
- Monitored ongoing cases closely, adjusting case management strategies as needed based on evolving circumstances or new information.
- Analyzed data to identify root causes of problems and recommend corrective actions.
- Worked diligently to resolve client disputes with insurance providers, advocating on their behalf for fair and satisfactory outcomes.
- Coordinated post-operative care plans with nursing staff to ensure a smooth transition from surgery to recovery for each patient.
- Streamlined communication between surgeons, patients, and hospital staff for seamless surgery coordination.
- Provided comprehensive customer service to drive client satisfaction.
Claims Processor
Kaiser Permanente
02.2012 - 03.2013
- Collaborated with cross-functional teams to resolve complex claims issues efficiently and effectively.
- Evaluated accuracy and quality of data entered into agency management system.
- Participated in various professional development opportunities to stay current on industry regulations, best practices, and emerging technologies relevant to claim processing activities.
- Followed up with customers on unresolved issues.
- Complied with regulations and guidelines related to claims processing to maintain quality and adherence to standards.
- Responded to customer inquiries, providing detailed explanations of insurance policies and claims processes.
Workers' Compensation Claims Adjuster
State Compensation Insurance Fund
06.2004 - 01.2012
- Used strong analytical and problem-solving skills to develop effective solutions for challenging situations.
- Reviewed questionable claims by conducting agent and claimant interviews to correct omissions and errors.
- Delivered exceptional customer service to policyholders by communicating important information and patiently listening to issues.
- Analyzed information gathered by investigation and reported findings and recommendations.
- Reviewed new files to determine current status of injury claim and to develop plan of action.
- Determined liability outlined in coverage and assessed documentation such from police and healthcare providers to understand damages incurred.
- Followed up on potentially fraudulent claims initiated by claims representatives.
Education
Associate of Science - English/Science
Mt. San Antonio College
San Dimas, CASkills
- Data and Analytics
- Case Management
- Medical terminology knowledge
- Electronic Charting
- Performance Improvement
- Physician support
- Patient relationship building
- Relationship building and management
- Complaint resolution
Timeline
Case Coordinator
Kaiser Permanente
03.2013 - Current
Claims Processor
Kaiser Permanente
02.2012 - 03.2013
Workers' Compensation Claims Adjuster
State Compensation Insurance Fund
06.2004 - 01.2012
Associate of Science - English/Science
Mt. San Antonio College