Evette Duarte
Riverside,CA
Summary
Customer Service Representative and Care Coordinator with over 7+ years of Customer Service experience. Seeking a full-time position that offers professional challenges utilizing interpersonal skills. I have worked with Medical Groups and Health Plans in handling patient care. Customer and goal orientated. Proven ability to meet deadlines.
Overview
5
5
years of professional experience
Work History
Case Manager Coordinator
Preferred IPA
02.2022 - 08.2023
- Line of Business DSNP (Cal Medi-Connect)
- Managed Low Risk and Medium Care Patients.
- Verified eligibility and benefits for all patients.
- Obtained pharmacy reports using LA Care website and Power BI for all patients.
- Outreached to provider offices to pertain patient medical records and other inquiries.
- Outreached to patients receiving Case Management Services.
- Outreached to pediatric patients receiving regional care services and provided CM services.
- Assisted in providing patients with authorization and claim status and assisted with authorization and claim complaints.
- Conducted thorough assessments of client needs, strengths, and risks to inform appropriate interventions and support services.
- Monitored progress towards goals regularly, adjusting case management plans as necessary for optimal success.
- Assessed community needs and identified resources for social and community service programs.
- Uploaded medical records into patients cases: Progress notes, their medication list and Lab work orders.
- Uploaded patient Health Risk Assessments to patients case les, setting ICP due dates by 30 days per HRA completion date .Mailed out finalized Care Plans (ICP's) to patients and providers.
- Data Transfers : Worked closely with LA care, transitioning patients in and out of the medical group. Created individual packets with most recent ICP's, ICT's and PPG contact list.
- Assisted with completing supervisor with Yearly Quarterly Reports.
- Received faxes (clerical work): Reviewed and uploaded Patient Case Management Referrals, Medical Records, LTCF records, claims and sorted them accordingly.
- Assisted with transition of care (TOC) patients.
- 30 or more outbound calls to patients and providers per day.
Authorizations Coordinator
Health Net
10.2021 - 02.2022
- Line of Business CALVIVA (Medi-cal).
- Conduct utilization review assessments to determine the medical necessity and appropriateness of requested healthcare services.
- Served as a liaison between patients, providers, and insurance companies, facilitating clear communication channels for optimal outcomes.
- Analyzed medical records and other relevant data to evaluate healthcare services and ensure compliance with industry standards and guidelines.
- Reviewed and interpreted insurance policies and guidelines to determine coverage eligibility and make recommendations for service approvals or denials.
- Coordinated with healthcare providers to obtain additional information, clarify documentation, and resolve any issues related to utilization review.
- Maintained accurate records of all authorization requests, ensuring timely follow-up and resolution.
- Collaborated with healthcare providers to obtain necessary medical information for accurate decision-making on authorizations.
Customer Service Representative
Regal Medical Group
09.2018 - 09.2021
- Lines of Business: Exchange, of Exchange, Cobra, Medi-cal, Cal Medi-Connect.
- Maintained detailed records of customer interactions, ensuring proper follow-up and resolution of issues.
- Resolved patient complaints with empathy, resulting in increased loyalty and repeat business.
- Managed high-stress situations effectively, maintaining professionalism under pressure while resolving disputes or conflicts.
- Handled escalated calls efficiently, finding satisfactory resolutions for both customers and the company alike.
- Verified eligibility and benefits for all patients.
- Used activity analysis reports from the health plans to make changes to existing terminations and address changes.
- 50-70 incoming calls per day assisting patients and providers on inquiries.
- Outreached to providers offices regarding member inquiries.
- Uploaded signed HIPAA Release Disclosure Forms.
- Provided patients with Authorization & Claims status and assisted with authorization and claim complaints.
- Properly distributed faxes to member services and provider services.
- Work together with the Coordination of Benefits team to verify members MSPs.
Education
High School Diploma -
Reseda High School
Skills
- Utilization review
- Case Management
- Decision-Making
- Organization and Multitasking
- Problem-Solving
- Medical Records Management
- MS Office
- Documentation And Reporting
- Multitasking Abilities
- Time management abilities
- Written and verbal communication
- Attention to Detail
Timeline
Case Manager Coordinator
Preferred IPA
02.2022 - 08.2023
Authorizations Coordinator
Health Net
10.2021 - 02.2022
Customer Service Representative
Regal Medical Group
09.2018 - 09.2021
High School Diploma -
Reseda High School
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