Gabriela Zuniga
Case Management
Montebello,CA
Summary
Patient care professional with extensive experience in coordinating healthcare services. Known for strong organizational skills, effective communication, and ability to adapt to changing circumstances. Excel in team collaboration, ensuring seamless patient experiences and achieving optimal outcomes. Skilled in managing patient records, scheduling, and liaising between patients and medical staff. Reliable and focused on delivering high-quality patient care.
Proactive and goal-oriented professional with excellent time management and problem-solving skills. Known for reliability and adaptability, with swift capacity to learn and apply new skills. Committed to leveraging these qualities to drive team success and contribute to organizational growth.
Overview
7
7
years of professional experience
1
1
Certification
Work History
Patient Care Coordinator
SBHIS
01.2025 - Current
- Oversee and support team
- Providing feedback, organizing team meetings, meeting goals and deadlines
- Communicating with upper management
- Customer service background
- Marketing and sales
- Visit local physician offices
- Visit senior living communities/ Hospice/ Home health
- Plan marketing events, marketing events with providers, pursue business opportunities
- Liaison between member and health plans
- Gather all paperwork needed to enroll or attend member needs and the need of needed services
- Negotiation with providers, business outreach
- Help Member enroll into a Medicare health plan, Medicare Advantage health plan, Medigap
- Explain the Medicare process to members
- Bring knowledgeable information to members in regards Medicare
- Explain to members health plan benefits, explain any copayments, deductibles, coinsurance, obtain premium statements
- Help members enroll with a primary PCP, supplemental plans, part D
- Follow up calls with members, liaison between provider and member
- License, certificate, contracts with health plans up to date, course training with health plans up to date, knowledge on open enrollment period
- Traveling to IPA, speaking with providers
- Help Veterans and homeless with resources and enrollment to health plan
Case Management
PIH Hospital
03.2023 - 01.2025
- Collaborate with multiple departments to engage, educate, communicate, coordinate patient needs, resources for patients
- Complete required documentation and electronic data
- Assist with preparation reports, safety plans, referrals, financial resource, assist with other services
- Clerical work, financial data gathering, patient admission, financial responsibility
- Analyzing and review claims from examiners for accuracy, making sure claims are being paid and process correctly per hospital contract and agreement using DOFER.
- Prepare spreadsheets for examiners, train new hires, and assist management.
- Review claims processes for examiners and troubleshoot complex claims and billing issues, risk adjustments for contracted IPA’s
- Exhibit strong communication and customer service skills, assisting both internal and external customers.
- Process all types of Medi-Cal, Medicare, Advantage, PPO, HMO, IPA, Dialysis, Hospital (UB), inpatient and outpatient claims, including behavioral health, emergency, dialysis, provider visits, ambulance, anesthesia, dermatology, nephrology, ophthalmology, surgery, podiatry, non-contract, urgent care, skilled nursing, and professional/facility claims.
- Perform prepayment audits according to department contracts and regulatory requirements.
- Manage eligibility verification, data entry, medical terminology, and claims processing (CPT, ICD-9 codes, third party, COB, prior authorizations).
- Resolve provider issues, verify vendor contracts, and improve work processes.
- Utilize programs such as Virtual Auth Tech, EZ-Cap, Office Ally, OptumRx, Excel, Word, Outlook, and others.
- Developed and implemented comprehensive case management plans to address client needs and goals.
- Improved client outcomes by conducting comprehensive assessments and developing tailored case management plans.
- Reduced claim processing time significantly through proactive case management strategies.
- Streamlined legal processes through the implementation of advanced case management tools and strategies.
- Enhanced client well-being by developing and implementing individualized case management plans.
- Maintained accurate documentation of client interactions, supporting case management efforts.
- Collaborated with fellow interns to develop strategies for effective case management and organization.
- Improved client mental health by implementing tailored therapeutic interventions and case management strategies.
- Collaborated with interdisciplinary teams for comprehensive case management and optimal results.
- Supported social workers in case management tasks, streamlining processes and increasing efficiency.
Provider Relations Coordinator
Blue Shield of California
02.2021 - 02.2022
- Assisted in the negotiation of contracts with healthcare providers, securing favorable terms that benefited both parties involved.
- Evaluated provider feedback regarding organizational processes or policies, sharing insights with relevant stakeholders for continuous improvement efforts.
- Managed caseloads effectively by utilizing strong organizational skills and prioritizing tasks based on urgency or importance levels related to provider relations objectives.
- Analyzed provider performance data, identifying opportunities for improvement and implementing targeted action plans.
- Contributed to the development of annual departmental goals and objectives, actively working towards their achievement through focused efforts and collaboration.
- Collaborated with network development teams to identify potential new providers, expanding the organization''s reach and services offered.
- Maintained accurate provider databases, ensuring up-to-date information was readily available for internal use and external reporting purposes.
- Organized educational events for healthcare providers to promote best practices and strengthen partnerships.
- Provided exceptional customer service to healthcare providers, demonstrating a commitment to their satisfaction and ongoing partnership.
- Served as a liaison between providers and various departments within the organization, facilitating effective communication and problem solving.
- Assisted in the preparation of regular reports for executive leadership, highlighting key provider relations metrics and trends for strategic decision-making purposes.
- Conducted regular provider audits to ensure compliance with company policies and industry regulations.
- Streamlined communication between healthcare providers and the organization, resulting in improved collaboration and efficiency.
- Answered provider inquiries via email, telephone and written correspondence.
- Monitored contractual agreements with providers, ensuring adherence to established terms and conditions while fostering positive working relationships.
Prior Authorization
United Health Care
01.2019 - 01.2021
- Managed inbound and outbound calls, processed provider authorizations, verified member information, and performed data entry.
- Troubleshot problem claims and collaborating with other departments resolved provider issues. Timely submission, follow up with providers or insurance, monitor turnaround times, denials and appeals
- Analyzed contracts, eligibility, medical terminology, and claims to ensure accuracy and completeness.
- Explained prior authorization procedures to providers and patients.
- Followed procedures for claims adjustments, denials, and payment determinations.
- Evaluated and negotiated claims per policies and guidelines.
- Maintained knowledge of state and federal regulations for Medi-Cal and Medicare.
Education
High School Diploma -
Montebello High School
Montebello, CA06-2010
Bachelor of Science - Clinical Psychology
Los Angeles Pacific University
San Dimas, CA05-2026
Associate of Arts - Human Development
East Los Angeles College
East Los Angeles,CA06-2012
Skills
- Behavioral health, emergency, dialysis, provider visits, ambulance, anesthesia, dermatology, nephrology, ophthalmology, surgery, podiatry, non-contract, urgent care, skilled nursing
- Critical thinking skills
- HIPAA compliance
- Appointment scheduling
- Organizational skills
- Customer service
- Patient relations
- Attention to detail
- Insurance verification
- Patient care
- Patient care coordination
- Patient confidentiality
- Medical terminology
- Patient education
- Goal setting
- Follow-up care
- Patient safety
- Filing and recordkeeping
- Office administration
- Relationship building
- Care planning
- Creative problem solving
- Claims processing
- Quality assurance
- Patient outreach and Follow-up
- Case management
- Organizational standards
- Project management
- Medical record requests
- Healthcare
- Calm and effective under pressure
- Punctual and hardworking
- Administrative and office support
- Registration and scheduling
- Patient intake
- Insurance authorizations
- Outbound calling
- Knowledge of community services and programs
- Spanish fluency
- Payment calculation
- Word processing
Certification
- Claims Examiner, Auditor, Provider Coordinator, case management, UM Coordinator, Appeals & Grievances, Health and Accident License & Life Insurance Agent. AHIP certification for Medical and Medicare, fraud, waste and abuse certification.
- Worker’s Compensation Course: 2025
- Injury
- FMLA
Languages
Spanish
Full Professional
Timeline
Patient Care Coordinator
SBHIS
01.2025 - Current
Case Management
PIH Hospital
03.2023 - 01.2025
Provider Relations Coordinator
Blue Shield of California
02.2021 - 02.2022
Prior Authorization
United Health Care
01.2019 - 01.2021
High School Diploma -
Montebello High School
Bachelor of Science - Clinical Psychology
Los Angeles Pacific University
Associate of Arts - Human Development
East Los Angeles College
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