Erika Najera
Phoenix,AZ
Summary
Dynamic Settlement Specialist with proven expertise at Wells Fargo in claims processing and data analysis. Adept at resolving conflicts and enhancing customer satisfaction through effective communication and negotiation techniques. Recognized for developing innovative payment plans and maintaining compliance with insurance verification standards in high-pressure environments.
Overview
10
10
years of professional experience
Work History
Retirement Services Specialist
Randstad-Vanguard
Scottsdale, AZ
08.2024 - Current
- Promoted high customer satisfaction by resolving problems with knowledgeable and friendly service.
- Recognized by management for providing exceptional customer service.
- Identified needs of customers promptly and efficiently.
- Assisted with customer requests and answered questions to improve satisfaction.
- Demonstrated strong problem-solving skills, resolving issues efficiently and effectively.
- Completed day-to-day duties accurately and efficiently.
Settlement Specialist
Wells Fargo
Phoenix, AZ
11.2023 - 08.2024
- Signed payment approvals accepted claims.
- Conducted comprehensive research and data analysis to support strategic planning and informed decision-making.
- Stayed calm and professional in situations and resolved conflicts to customer satisfaction.
- Put together settlement options and development payment plans.
- Managed a high volume of incoming calls while providing excellent customer service.
Prior Authorization Specialist
CVScaremark
Phoenix, AZ
07.2022 - 08.2023
- Input claim, prior authorization, and other important medical data into system.
- Communicated authorization decisions, including approvals and denials, to healthcare providers and patients.
- Scheduled peer to peer reviews for physicians to discuss medical necessity with insurance providers.
- Reviewed prior authorization requests to ensure accuracy and completeness of required information.
- Evaluated patient eligibility and benefits for requested procedures and medications.
- Educated healthcare professionals on how to properly submit a request for pre-authorization.
- Verified patient insurance coverage, including eligibility, benefits and authorizations for medical services.
Prior Authorization Coordinator
Randstad-CVS
Phoenix, AZ
02.2022 - 07.2022
- Maintained a professional attitude when interacting with external customers such as physicians' offices or insurance companies.
- Compiled data from multiple sources for reporting purposes.
- Input claim, prior authorization, and other important medical data into system.
- Determined which party would be liable for payment on medical services by thoroughly reviewing patient insurance coverage.
- Identified reasons behind denied claims and worked closely with insurance carriers to promote resolutions.
- Educated healthcare providers on prior authorization requirements and insurance formulary changes.
- Followed up on pending prior authorization requests to ensure timely processing.
- Utilized medical coding knowledge to accurately process and document authorization requests.
- Scheduled peer to peer reviews for physicians to discuss medical necessity with insurance providers.
- Communicated authorization decisions, including approvals and denials, to healthcare providers and patients.
Customer Service Representative
National General Insurance Company
Messa, AZ
02.2019 - 10.2021
- Resolved customer complaints promptly and efficiently.d
- Prepared and submitted detailed reports on insurance verification activities and outcomes.
- Performed daily audits of submitted claims to ensure compliance with industry standards and regulations.
Technical Support Representative/Customer Sales Representative
Consumer Cellular
Tempe, AZ
01.2017 - 01.2019
- Diagnosed system errors and implemented solutions to resolve them.
- Assisted customers with password resets, account unlocks, and security settings adjustments.
- Guided customers through step-by-step solutions in a clear and concise manner.
- Served as first point of contact for incoming technical service calls and emails.
- Demonstrated advanced product knowledge to solve customer issues.
- Adhered to company initiatives and achieved established goals.
- Demonstrated product features and benefits for customers' needs.
Customer Service Representative
MTBA
Phoenix, AZ
10.2015 - 01.2017
- Scheduled and confirmed patient appointments and consultations.
- Maintained up-to-date knowledge of insurance policies, including Medicare and Medicaid.
- Maintained confidentiality of patient information in accordance with HIPAA regulations.
- Managed multiple tasks and priorities in a high-volume, fast-paced environment.
- Educated patients on their insurance benefits and coverage limitations.
- Collaborated with multi-disciplinary staff to improve overall patient care and response times.
- Navigated through multiple online systems to obtain documentation.
Education
High School Diploma -
South Mountain
Phoenix, AZ05-2005
Skills
- Claims processing
- Data analysis
- Payment approval
- Medical coding
- Insurance verification
- Customer service
- Research skills
- Problem solving
- Team collaboration
- Prior authorization
- Negotiation techniques
Languages
Spanish
Native/ Bilingual
Timeline
Retirement Services Specialist
Randstad-Vanguard
08.2024 - Current
Settlement Specialist
Wells Fargo
11.2023 - 08.2024
Prior Authorization Specialist
CVScaremark
07.2022 - 08.2023
Prior Authorization Coordinator
Randstad-CVS
02.2022 - 07.2022
Customer Service Representative
National General Insurance Company
02.2019 - 10.2021
Technical Support Representative/Customer Sales Representative
Consumer Cellular
01.2017 - 01.2019
Customer Service Representative
MTBA
10.2015 - 01.2017
High School Diploma -
South Mountain
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