Carolina Peralta
East Elmhurst,NY
Summary
Licensed esthetician with experience in customer service. Seeking a position as an esthetician where I can utilize my skills in skincare and customer engagement to contribute to client satisfaction, product sales, and overall business success.
Overview
9
9
years of professional experience
1
1
Certification
Work History
Provider Network Support Specialist II
Fidelis Care
09.2023 - Current
- Perform day to day duties of assuring that providers (individual, group, ancillary, etc.) are set up accurately in the provider information system for state reporting, claims payment, and directories
- Responsible for multiple state deliverables, network reporting and directories as well as claims payment resolution as it relates to provider set up
- Provide support to the external provider representative to resolve provider data issues
- Research and effectively respond to provider related issues
- Submit provider data entries to resolve provider-related demographic information changes
- Research and identify any processing inaccuracies in claim payments and route to the appropriate site operations team for claim adjustment
- Initiate and process provider add, change and termination forms
- Create and maintain spreadsheets used to produce provider directories for multiple products
- Track, update and audit provider data
Provider Relations Specialist II
Fidelis Care
01.2021 - 09.2023
- Serve as a liaison between providers, the health plan and corporate to investigate and resolve provider claims
- Investigate and respond to complex provider related issues and initiate change of provider related database information
- Serve as a subject matter expert for provider relations activities
- Serve as a lead for key special projects
- Conduct on site provider orientations, including writing and updating orientation materials and assisting providers acclimated to plan website
- Monitor financial performances of contracts
- Investigate and document provider changes and correspondence
Provider Services Associate
Fidelis Care
01.2019 - 01.2021
- Responsible for administrative support of Provider services staff: takes and conveys telephone messages, sends and receives faxes, retrieves and forwards provider information
- Interact with providers in a positive and effective manner to facilitate demographic practice information changes and participating status updates
- Provide information to the Provider Relations Representative to assist in gathering data from providers for access and availability studies, QARR record collection, and other projects as assigned
- Knowledge of various quality programs, including measures associated with QARR and HEDIS
Enrollment Associate
Fidelis Care
10.2015 - 01.2019
- Data entry, record, input, update, and edit information efficiently and effectively
- Responsible for updating customer account information
- Experienced with Child Health Plus, NYS Essential Planning, and NY Health Exchange
- Performs quality assurance for Child Health Plus, NYS Essential Planning, Qualified Health Plan, KIDS applications, Facets, and CSI’s to determine members eligibility
- Revise and assess all documentations ensuring members account is reflected correctly; consistently exceeds departmental quality and production requirements
- Processes proofs received daily to finalize the eligibility and enrollment of incomplete application
- Assist upper management with specific projects for deadlines
- Updates the Kids applications database for Child Health Plus members such as effective date, termination date and personal information
- Selected to support assistance to the Kids Department division in analyzing and processing daily transactions of Child Health Plus errors and denials to ensure the submission of a clean bill by the scheduled monthly billing date to the State
Education
Esthetics -
Atelier Esthetique Institute of Esthetics
New York, NY12-2024
Foods, Nutrition, and Wellness Studies Certificate -
Institute For Integrative Nutrition
New York, NY01.2019
Skills
- Dynamic customer service
- High-level customer service
- Highly organized
- Teamwork
- Results-oriented problem solving
- Analytical skills
- Communication skills
- Time management
- Prioritizing
- Computer software applications
- Multitasking and organization
- Problem-solving
- Self motivation
- Superior attention to detail
- Relationship building
Certification
Foods, Nutrition, and Wellness Studies Certificate
Languages
Spanish
Native or Bilingual
Timeline
Provider Network Support Specialist II
Fidelis Care
09.2023 - Current
Provider Relations Specialist II
Fidelis Care
01.2021 - 09.2023
Provider Services Associate
Fidelis Care
01.2019 - 01.2021
Enrollment Associate
Fidelis Care
10.2015 - 01.2019
Esthetics -
Atelier Esthetique Institute of Esthetics
Foods, Nutrition, and Wellness Studies Certificate -
Institute For Integrative Nutrition
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