Gabie Zavala

Assisted with daily escalation calls through Teams chat and email. Processed transportation requests and arranged transportation for member appointments and discharges via phone and email using Medhok and logging in to different IPA portal .(entering idc -10 and CPT Provided mentoring support to team members. Reviewed team member calls for quality assurance. Monitored wall board for incoming calls and conducted silent monitoring for quality. Pulled reports from Medhok for inventory and workload management. Supported grievance response efforts from the grievance department. Participated in skilled nursing virtual visits with the provider relations team. Facilitated team huddles and communicated reminder metrics and recognition to the team. Maintained a tracker for trending items and assisted with redirection from broker companies and vendors.

Scheduled appointments for primary care services, ensuring smooth coordination and timely patient access. Assisted in submitting authorization requests to medical groups for pre-approval, supporting efficient patient care. Handled pre-certification requests for pharmacy prescriptions, maintaining accuracy and speed. Accurately completed CMS 1500 forms, contributing to efficient billing processes.

• Executed processing of prior authorization requests to ensure adherence to regulatory guidelines.
• Facilitated collaboration with healthcare providers to secure essential documentation for approval processes.
• Reviewed medical necessity criteria to assess service eligibility. Performed data entry using CPT codes for procedures and ICD-10 co-pays and deductibles. Assisted with workers' compensation cases as needed.

Assisted in confirming eligibility and coverage for ambulatory surgery center and ophthalmologist services. Verified patient eligibility one day prior to scheduled surgeries. Processed prior authorization requests. Checked eligibility for all members on the schedule the day before appointments.