Fernanda Resillas
Lancaster,CA
Summary
Healthcare Operations Specialist with 8+ years of experience in utilization management, continuity of care, and Medi-Cal operations. Extensive background supporting regulatory compliance, conducting detailed chart reviews, and care coordination across health plans including Kaiser Permanente and Blue Shield of California. Proven ability to support financial performance initiatives, develop training material, and ensure timely compliant service delivery for members and providers.
Overview
11
11
years of professional experience
2
2
Certifications
Work History
Operation Specialist
Medasource-Kaiser Permanente
Oakland, CA
01.2024 - Current
- Coordinated services for Medi-Cal members transitioning to Kaiser Permanente, enhancing continuity of care.
- Intake and case review, help identify qualifying conditions, confirm provider network status and decision.
- Chart review, ensure documentation supports criteria.
- Monitored regulatory turnaround times to ensure compliance with state Medi-Cal regulations.
- Support the Utilization and Financial Performance Management Team, chart review to identify patients who have Special Mental Health needs.
- Developed training materials and facilitated onboarding process for new staff.
Social Determinants of Health Advanced Coordinator
Blue Shield of California
Monterey Park, CA
01.2023 - 11.2023
- Coordinated access to social work services for patients with mental health needs, enhancing their support network.
- Utilized Unite Us and Find Help to research community resources for members experiencing food, and housing insecurities.
- Conducted health risk assessments via telephone to identify patient needs.
- Developed reports and contact logs to support case management reviews.
- Invited providers to attend Individual Care Team meetings.
UM Long Term Care Coordinator
Blue Shield of California
Monterey Park, CA
08.2021 - 01.2023
- Initial point of contact for providers in Medi-Cal management.
- Processed faxed authorization requests and facilitated timely referrals for patient care.
- Assisted with discharge planning by coordinating DME and Home Health for patients.
- Compiled monthly report on disenrollments from medical group to inform management decisions.
- Maintained comprehensive knowledge of policies, procedures, and guidelines to ensure compliance and support team operations.
UM Inpatient Coordinator
Imperial Health Holdings Medical Group
Pasadena, CA
08.2020 - 08.2021
- Coordinated authorizations for inpatient hospital stays and skilled nursing facility admissions.
- Coordinated discharge planning, creating Home Health and DME authorizations to ensure seamless transitions for patients returning home.
- Requested and obtained medical records, submitting appeal documentation and last cover day letters to facilitate timely patient care.
- Provided support for authorization status inquiries and patient transfer coordination.
Authorization Specialist
City of Hope
Irwindale, CA
04.2020 - 08.2020
- Obtained physician referrals, authorizations, and pre-certifications for patients, ensuring compliance with insurance company requirements.
- Verified accuracy of CPT and ICD10 codes prior to processing authorization requests.
- Entered authorization information in Epic, closed referrals, and communicated effectively with office staff.
UM Inpatient Coordinator
Blue Shield of California
Monterey Park, CA
03.2017 - 01.2020
- Coordinated daily inpatient census reports and entered inpatient authorizations to support Case Managers.
- Managed processing of inpatient authorization requests from hospitals to ensure timely patient care.
- Facilitated phone support for Emergency Room admissions and patient transfers to enhance operational flow.
Member Services Representative
Care 1st Health Plan
Monterey Park, CA
12.2015 - 05.2016
- Provided excellent customer care by guiding members and explaining the correct process to obtain medical services.
- Assisted members with authorizations by contacting medical groups and revising time frames to ensure compliance.
- Provided resources to help members feel comfortable and valued.
Pediatrics & Adolescent Medicine Medical Assistant
White Memorial Medical Center
Los Angeles, CA
04.2015 - 12.2015
- Filed medical records, monitored phone calls, scheduled patients and verified eligibility by contacting insurance companies.
- Assisted physicians by prepping exam rooms, taking patients’ vital signs, and administering vaccines to support patient care.
Education
Medical Assistant Certification -
Los Angeles Occupational Center
Los Angeles, CAMedical Terminology Certification -
East Los Angeles Skills Center
Los Angeles, CAHigh School Diploma -
Schurr High School
Montebello, CASkills
- Continuity of care coordination
- Utilization management
- Medi-Cal compliance
- Chart and clinical documentation review
- Transition of care
- Cross-functional collaboration
- Process improvement
- Critical thinking
- Adaptability
- Problem solving
- Effective communication
References
Available Upon Request
Certification
Medical Assistant
Timeline
Operation Specialist
Medasource-Kaiser Permanente
01.2024 - Current
Social Determinants of Health Advanced Coordinator
Blue Shield of California
01.2023 - 11.2023
UM Long Term Care Coordinator
Blue Shield of California
08.2021 - 01.2023
UM Inpatient Coordinator
Imperial Health Holdings Medical Group
08.2020 - 08.2021
Authorization Specialist
City of Hope
04.2020 - 08.2020
UM Inpatient Coordinator
Blue Shield of California
03.2017 - 01.2020
Member Services Representative
Care 1st Health Plan
12.2015 - 05.2016
Pediatrics & Adolescent Medicine Medical Assistant
White Memorial Medical Center
04.2015 - 12.2015
Medical Assistant Certification -
Los Angeles Occupational Center
Medical Terminology Certification -
East Los Angeles Skills Center
High School Diploma -
Schurr High School