DALIA CARVAJAL

• Enhanced patient care cases by effectively coordinating medical requests, notifications, preauthorizations, and eligibility questions via phone, emails from member, providers, physicians, or Third party for assigned regions, handling within a given deadline and serve objections (Domestic/ International)

Read physicians medical information and decide on compensability and/or exclusions, review claims against policy benefits to determine coverage and exclusions

• Make decisions or determine the need to scale complex cases according to the case segmentation process that may require higher level of evaluation
• Expedite with ICD-10 Codes and Procedure codes for approval of services in a timely manner

Send letter of approvals or denials and explanation of benefits depending on the outcome of the claim evaluation

• Successfully negotiated rates with providers, or third parties outside the Network using usual and customary rates to maintain revenue
• Enter system date for notes on every tasks of emails, phone conversations, and decisions into the system for company wide for record keeping
• Recorded daily work onto Excel spreadsheet for surgeries and doctors visits
• Collaborate closely with insurance companies to resolve any discrepancies or coverage issues on behalf of patients quickly, reducing financial stress for individuals and families
• Trained newly hired employees
• Collaborated with medical team manager to maintain daily operations

• Organized notifications, managed medical requests, authorizations and benefit questions via emails from members, providers, physicians, or Third party for assigned regions (Domestic/International)
• Worked with ICD10 codes and procedures codes for approval of services in a timely manner
• Send letter of authorizations or denials giving explanation of benefits after claim being medically evaluated
• Determine the approval after receiving medical information to decide compensability and/or exclusions
• Handled customer service calls by giving benefits to members, providers, and/or medical care services

Negotiated rates with providers or Third party outside the insurance network using usual and customary fees

• Gave remarkable customer service via phones, emails, and face to face appointments for members and providers
• Coordinate benefit eligibility, co-pays, exclusions, and determined the need for physicians or facility referrals, and need for admission care
• Negotiate rates with providers, or Third party outside the network using unusual and customary rates
• Make decisions on payment or denials of claims within limits, follow protocol on transplant cases, including verification of benefit letters, preauthorizations, procedures, and steer insured with proper providers
• Coordinated the air ambulance process with patients and providers for a smooth transition

• Implemented excellent customer service answering phones, giving appointments, verification of insurance policies and benefits
• Managed to collect co-pays and prepared deposit slips from day to day operations
• Scheduled surgery procedures following protocols and made sure to collect proper documents that needed approval and signatures
• Made calls daily to patients explaining the verification required to meet surgical protocols

Prepared referrals , call in prescriptions, and entered encounters into the computer by being aware of procedure codes and ICD-9 codes