Carmen Maestre

• Create and maintain final employer Benefit Summaries and SBCs, ensuring accuracy of client intent
• Manage required source documents through the document storage process.
• Document quality error findings.
• Check employees' benefits enrollment for accuracy and input all data into BenKit (software system).
• Implemented open enrollment system to streamline benefits processes for employees.
• Observed strict procedures to maintain data and plan participant confidentiality.
• Researched and evaluated new benefits programs to select cost-effective providers and coverage levels.

• Addressed special issues affecting participants and considered barriers to employment in program placement decisions
• Gained customer trust by providing knowledgeable and accurate information in both English and Spanish.
• Referred applicants and participants to community resources and provided follow-up.
• Actively listened to customers, handled concerns quickly and escalated major issues to supervisor.
• Met all call quality standards and daily quotas for first-call resolution.
• Placed 250-300 outbound calls per day, supporting connections to job placement, healthcare, and transportation resources.
• Responded to customer requests, offering excellent support and tailored recommendations to address needs.

• Verified patient medical Insurance.
• Verified benefits and eligibility via Pharmacy Benefit Managers for specialty medications.
• Managed daily work queues independently, resolving issues in a timely manner.
• Documented and initiated prior authorizations and claims appeals.
• Completed quality review of work and reported reimbursement trends or delays to management.
• Evaluated clinical criteria for approval or denial of services requiring pre-authorization.
• Verified eligibility and compliance with authorization requirements for service providers.
• Researched denied claims and contacted insurance companies to resolve these issues.
• Reviewed appeals for prior authorization requests and communicated with payers to resolve issues.

• Processed documents for scanning and indexing, ensuring optimal image results
• Reviewed the quality of scanned patient medical records and indexed patient charts for highest quality
• Prepared and sorted documents, removed staples, applied correct labels, and scanned batches accurately.
• Navigated within patient records to locate requested documentation, successfully completing over 50 requests per day.
• Resolved medical record discrepancies by collecting and analyzing information.

• Managed requests for release of information, ensuring proper authorization and adherence to privacy laws
• Reviewed and assessed documents, identifying confidential or sensitive information for redaction or special handling
• Maintained organized and secured records of released information, adhering to record retention policies.
• Sorted, scanned and indexed documents, developed workflows and processed workflow reports to keep clinical records maintained in accordance with guidelines.

• Scheduled patient appointments and placed reminder calls to deliver exceptional customer experience.
• Organized paperwork such as charts and reports for office and patient needs.
• Answered telephone calls to offer office information, answer questions, and direct calls to staff.
• Coordinated patient scheduling, check-in, check-out and payments for billing.
• Adhered to strict HIPAA guidelines to protect patient privacy.
• Gathered forms and copied insurance cards to collect patient information for billing and insurance filing.
• Obtained pre-authorization from insurance companies ahead of medical services.
• Coordinated referrals through insurance and other medical specialists and documented details in patient charts.
• Assisted with medical coding and billing tasks.
• Placed new supply orders, managed inventory and restocked clerical spaces.
• Received and routed laboratory results to correct clinical staff members.

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