Elona Zenon

• Responded via telephone and email to questions regarding licensing, commissions, website logins and website navigation.
• Provided customer support and follow-up with members as assigned, implementing exceptional problem-solving and management and responding appropriately to inquiries.
• Answered inquiries and provided information to Brokers, distributed appropriate paperwork, and fulfilled quote requests to deliver excellent customer support.

Answering High volume calls from member and provider regarding dental claims and benefits. Verifying dental benefits, such as COB, Annual Maximum, Ortho coverage and submitting written and verbal adjustment for dental claims. Verify in-network and Out network provider benefits.

• Handled heavy incoming calls from members with complaints, billing questions and payment extension/ service requests.

• Calmed down angry callers, repaired trust, located resources for problem resolution and designed bestoption solutions.

• Assisted members with healthcare benefits.

• Assisted and processed enrollment telephonic agreement during annual re-enrollment period.

• Knowledge of HIPAA, EOC, EOB, formulary, Medicare, medical, dental benefits.

• Provided and verified eligibility of health coverage to providers. • Handled grievance and appeals, insurance verification, empathy and compassion for seniors and disable members. Provides new and existing members with the best possible service in relation to billing inquiries, service requests, suggestions and complaints. Resolves member inquiries and complaints fairly and effectively. Provides product and service information to members, and identifies opportunities to maintain and increase member relationships. Recommends and implements programs to support member needs

Works within the Care Access and Monitoring (CAM) team to provide clerical and data entry support for Molina Members that require hospitalization and/or utilization review for other healthcare services. Checks eligibility and verifies benefits, obtains and enters data into systems, processes requests, and triages members and information to the appropriate Health Care Services staff to ensure the delivery of integrated high quality, cost-effective healthcare services according to State and Federal requirements to achieve optimal outcomes for Molina Members. Essential Functions

• Provide computer entries of authorization request/provider inquiries by phone, mail, or fax. Including:

o Verify member eligibility and benefits,

o Determine provider contracting status and appropriateness,

o Determine diagnosis and treatment request

o Determine COB status, o Verify inpatient hospital census-admits and discharges o Perform action required per protocol using the appropriate Database

• Meet department productivity standards.

• Respond to requests for authorization of services submitted to CAM via phone, fax and mail according to Molina operational timeframes.

• Contact physician offices according to Department guidelines to request missing information from authorization requests or for additional information as requested by the Medical Director.

• Provide excellent customer service for internal and external customers.

• Meet department quality standards, including inter-rater reliability (IRR) testing and quality review audit scores.

• Notify Care Access and Monitoring Nurses and case managers of hospital admissions and changes in member status.

• Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA)

• Participate in Care Access and Monitoring meetings as an active member of the team.

• Meet attendance guidelines per Molina Healthcare policy.

• Follow "Standards of Conduct" guidelines as described in Molina Healthcare HR policy.

• Comply with required workplace safety standards. Knowledge/Skills/Abilities

• Demonstrated ability to communicate, problem solve, and work effectively with people.

• Working knowledge of medical terminology and abbreviations.

• Ability to think analytically and to problem solve.

• Good communication and interpersonal/team skills.

• Must have a high regard for confidential information. • Ability to work in a fast paced environment.

• Able to work independently and as part of a team.

• Computer skills and experienced user of Microsoft Office software. • Accurate data entry at 40 WPM minimum.

Accurately enter required information (non-clinical and structured clinical data) into computer database for Pre Auth claims for payments for approval and denial claims Utilize ICD-9 and CPT Codes To ensure that aides are paid on a timely manner Preview billing for errors in service codes, service dates, service authorizations or other issues

Follow up with the coordination team to obtain missing authorization/preapproval to bill Review "billed not exported" report & take corrective action Review & Correct return/denied billing Save various e-billing & invoices files on the shared drive Any other duties as directed by management

• Contacted provider offices via phone to schedule medical record technicians to go on-site to retrieve health records that are then uploaded into our systems to be coded by our medical coding staff.

• Contacted health plan members to schedule an office or home visit by a physician, and as well to offer the health plan members different social services that they may qualify for in Los Angeles.

• Supported incoming calls from coders, medical record technicians, provider offices & health plan members

• Prepared, sent, and received provider & member correspondence

• Reported on productivity

• Prepared other reports and reconciled scheduling data. Also verified all the forms receive in the office to be complete.

• Performed special assignments as required

• Handled heavy incoming calls from members with complaints, billing questions and payment extension/ service requests.

• Calmed down angry callers, repaired trust, located resources for problem resolution and designed bestoption solutions.

• Assisted members with healthcare benefits.

• Assisted and processed enrollment telephonic agreement during annual re-enrollment period.

• Knowledge of HIPAA, EOC, EOB, formulary, Medicare, medical, dental benefits.

• Provided and verified eligibility of health coverage to providers.

• Handled grievance and appeals, insurance verification, empathy and compassion for seniors and disable members.

• Made outbound call to new members with diabetes welcome them to new plan and to discuss diabetic supplies