Evelyn Ortega-Garcia
Case manager
San Diego,CA
Summary
Support day-to-day program operations with expertise in patient case management and resource coordination. Skillfully meet diverse needs and address issues to maintain efficiency and program outreach. Demonstrated success in building long-lasting relationships with patients and their Care team to help them navigate complexities in access to therapy.
Overview
19
19
years of professional experience
1
1
Certification
Work History
Reimbursement Analyst
Occam Health Services
09.2023 - Current
- Collaborated with healthcare providers to ensure accurate billing information for prompt reimbursements.
- Increased patient satisfaction with clear explanations of benefits, coverage limits, and out-of-pocket expenses related to their treatments.
- Provided exceptional customer service, assisting patients with inquiries related to their insurance coverage and reimbursement status.
- Built strong relationships with payer representatives, facilitating efficient communication channels for improved collaboration on claim resolution matters.
- Managed high volume caseloads effectively while maintaining strict deadlines for submission of claims or appeals documentation.
- Followed up on denied and unpaid claims to resolve problems and obtain payments.
- Guided office staff on how to effectively complete prior authorization forms and appeals documentation to achieve positive results.
Program Specialist, Patient Support Solutions
Fortrea (formerly Known As: Labcorp)
10.2014 - 09.2023
- Facilitated Case Management support across patients continuum of care. Functions included but not limited to: Confirm benefits and eligibility to access therapy via pharmacy benefits, collaborated with Treating Prescriber to manage coverage request to insurance (i.e, Prior Authorization/Appeal), evaluated affordability options for patients (i.e., copay enrollment, Patient Assistance foundation, and other means of support to cover cost of therapy).
- Performed documentation of several documents to communicate with patients/provider to maintain updates throughout journey of their case.
- Supported across multiple areas of program including data entry and inbound support based on resourcing for the day.
- Served as a liaison with partner distributors and pharmaceutical manufacturers to request products per the program's guidelines and track shipments to ensure timely delivery to patient.
- Coordinated with the non-commercial pharmacy when patients had to be transferred over to a commercial pharmacy as a result of gaining coverage through their insurance.
- Provided educational support to providers and patients to create awareness in payer landscape as it relates to the specific product/therapeutic area, online resources, and tools to facilitate a enhanced customer experience.
- Led a team of 6 agents that were part of our Emergency Supply Requests program for a Hepatitis C product. Due to the nature of urgency to avoid lapse in therapy, I was primarily in charge of reviewing every request to ensure it met the appropriate eligibility to dispense. Due to the effectiveness rate of this product and high cost - there was a high demand of request each day (>100 requests per day).
- Served as an assistant to the Program Supervisor to manage quality checks on the program, reporting, and development of training materials.
- Supported facilitation of training throughout the continuation of our program for a class size of approx. ~16 call center agents.
- As necessary, I was invited to discussions with the Pharmaceutical company to share my experience as a front end operator interacting with patients/providers.
Dental Assistant
Town And Country Dental Specialty Group
01.2013 - 10.2014
- Cleaned and sanitized dental tools and equipment, straightened treatment rooms, and restocked supplies to prep for next patient and maintain health and safety practices.
- Sanitized trays, instruments, and surfaces for clean dental office setting and patient safety.
- Successfully assisted dentist by performing four-handed dentistry and other chair-side duties.
- Performed general chair-side duties for general dentistry, endo procedures, and oral surgery.
- Prepared patient x-rays and images for dentist review.
- Assisted dentists, hygienists, and other personnel by handing appropriate tools and supplies needed for procedures.
- Maintained dental supply inventory by checking stock to determine inventory levels and placing and expediting orders for supplies.
- Explained treatment procedures and instructed patients on home care guidelines.
- Educated patients by giving oral hygiene, plaque control, and postoperative instructions.
- Scheduled and confirmed patient appointments.
Dental Assistant
United States Army
02.2006 - 02.2012
- Cleaned and sanitized dental tools and equipment, straightened treatment rooms, and restocked supplies to prep for next patient and maintain health and safety practices.
- Sanitized trays, instruments, and surfaces for clean dental office setting and patient safety.
- Successfully assisted dentist by performing four-handed dentistry and other chair-side duties.
- Performed general chair-side duties for general dentistry, endo procedures, and oral surgery.
- Prepared patient x-rays and images for dentist review.
- Assisted dentists, hygienists, and other personnel by handing appropriate tools and supplies needed for procedures.
- Maintained dental supply inventory by checking stock to determine inventory levels and placing and expediting orders for supplies.
- Explained treatment procedures and instructed patients on home care guidelines.
- Educated patients by giving oral hygiene, plaque control, and postoperative instructions.
- Scheduled and confirmed patient appointments.
Education
Certified Dental Assistant -
Southwestern College
880 National City Blvd. National City, CA 9195012.2004
High School Diploma -
Junipero Serra High School
5156 Santo Rd. San Diego, CA 9212406.2003
Skills
- Ability to resolve complex situations
- Effective communication
- Time Management/Multi-tasking
- Cultural Sensitivity
- Patient Advocacy
- Microsoft and Excel Proficient
- Care Coordination
- Collaboration and teamwork
- Organization
- Cultural Sensitivity
- Customer Service
Accomplishments
- Achieved Quality standards by completing >96% of tasks with accuracy and efficiency.
- Supported development and execution of training for new employee onboarding.
- Documented and resolved Emergency Requests for Hepatitis C product which led to achieving the productivity standards (>95% of requests) to process shipment of therapy to patients.
- Maintained and monitored data quality reports to ensure client reports were delivered accurately and on time.
- Conducted a number of Quality case audits and ongoing coaching for new trainees which led to a successful graduation to perform their tasks independently within 4 weeks post training completion.
Certification
- Certified Dental Assistant - 2006 to Present
Languages
Spanish
Native or Bilingual
Timeline
Reimbursement Analyst
Occam Health Services
09.2023 - Current
Program Specialist, Patient Support Solutions
Fortrea (formerly Known As: Labcorp)
10.2014 - 09.2023
Dental Assistant
Town And Country Dental Specialty Group
01.2013 - 10.2014
Dental Assistant
United States Army
02.2006 - 02.2012
Certified Dental Assistant -
Southwestern College
High School Diploma -
Junipero Serra High School
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