CYNTIA RONSANO
Miami
Summary
I am a highly qualified healthcare industry professional with ample experience in Medicare and Medicaid managed-care, customer service and health insurance plan operations.
Highly-motivated employee with desire to take on new challenges. Strong work ethic, adaptability, and exceptional interpersonal skills. Adept at working effectively unsupervised and quickly mastering new skills.
Overview
13
13
years of professional experience
2008
2008
years of post-secondary education
Work History
Grievance and Appeals Professional II
CarePlus Health Plans/ Humana
Miami
06.2023 - Current
- Manage client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if a grievance, appeal or further request is warranted and then delivers final determination based on trained skillsets and/or partnerships with clinical and other Humana parties.
- Assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
- Assists members, requestors and providers via phone with further/support quality related goals.
- Investigates and resolves member and practitioner issues.
- Understanding of department, segment, and organizational strategy and operating objectives, including their linkages to related areas.
- Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.
- Follows established Medicare supplemental guidelines/procedures.
Grievance and Appeals representative III
CarePlus Health Plans/ Humana
Miami
08.2019 - 06.2023
- Handling Waiver of Liability cases in order to proceed with the appropriate non-participating provider appeal process, form validation.
- Handling Appointment of Representative cases in order to proceed with the appropriate member grievance and/or appeal process, form validation.
- Manage client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if a grievance, appeal or further request is warranted and then delivers final determination based on trained skillsets and/or partnerships with clinical and other Humana parties.
- Preform advanced administrative/operational/customer support duties that require independent initiative and judgment.
- Submission of IRE packets to Maximus Federal services.
- Assist via multiple communication methods, assuring that members and health care providers receive exceptional service when acknowledging, discussing, documenting or responding to their issue of dissatisfaction.
- Decisions are typically focused on methods, and processes for completing administrative tasks/projects.
- Regularly exercise discretion and judgment when prioritizing requests while interpreting and adapting procedures.
- Work under limited guidance due to previous experience/breadth and depth of knowledge of administrative processes and Medicare advantage organizational knowledge.
- Responded to customer questions and complaints while documenting consumer communications.
- (Remote) Miami, FL
Work Content Specialist
CarePlus Health Plans / Humana
Doral
09.2015 - 08.2019
- Completed quality and auditing reviews in compliance with CMS rules and regulations.
- Reviewed documentation to assess that appropriate system entries have been thoroughly completed to mitigate risk associated with external departments.
- Served as a subject matter expert for the submission of all dental and mental organization determination requests.
- Verified that proper resolution was provided prior to the case submission to the Grievance and Appeals Department.
- Assisted upper management with any special projects and high importance matters that required immediate attention and resolution.
- Review Grievance cases received from non-authorized invalid requestor (AOR), to determine applicability and compliance with Medicare regulations, enterprise policies and procedures and all related accreditation standards.
- Evaluate urgency of grievances and or appeals to ensure appropriate handling, confirm that sufficient records were obtained and review medical records and medical policies to determine if correct criteria have been utilized for each review.
- Identified and communicated error trends to improve overall quality of Grievance and Appeals.
- Review and perform daily audits to all the Dental Organization Determinations cases we received through the call Center.
- Communicating over the phone and email with CarePlus Dental provider (Argus Dental) to process the authorizations within timely manner.
- Doral, FL
Customer Service Representative
CarePlus Health Plans / Humana
Doral
09.2013 - 09.2015
- Performed operational customer support.
- Addressed incoming telephone, digital, or written customer inquiries.
- Addressed customer needs which may include complex benefit questions, resolving issues, and educating members.
- Recorded details of inquiries, comments or complaints, transactions or interactions and took action in accordance to it.
- Worked within established policies/practices and guidelines with minimal supervision.
- Assist management on side projects or other duties as assigned.
- Doral, FL
Education
Associates Degree - Business Administration
Miami Dade College
Miami, FLSkills
- Fluent in English
- Fluent in Spanish
- Fast learner
- Easily adaptable to change
- Active listener
- Excellent communication
- Highly organized
- Independent work
- Teamwork
- Strong analytical thinking
- Effective problem solving
- Project management
- Deadline management
- Proficient in Microsoft Office
- Proficient in Word
- Proficient in Excel
- Proficient in Outlook
- Proficient in PowerPoint
- Proficient in Access
Timeline
Grievance and Appeals Professional II
CarePlus Health Plans/ Humana
06.2023 - Current
Grievance and Appeals representative III
CarePlus Health Plans/ Humana
08.2019 - 06.2023
Work Content Specialist
CarePlus Health Plans / Humana
09.2015 - 08.2019
Customer Service Representative
CarePlus Health Plans / Humana
09.2013 - 09.2015
Associates Degree - Business Administration
Miami Dade College