Open To Work
Gina L. Silva
Zephyrhills
Work Preference
Summary
Hard-working seasoned Patient Care Advocate who maintains a high level of professionalism, patience, empathy and efficiency to ensure patient satisfaction. Highly organized and detail-oriented with a strong background in healthcare administration, seeking a position to utilize my expertise, ensuring seamless communication between healthcare providers and members.
Overview
22
22
years of professional experience
Work History
Medical Management Rep I
Elevance Health Plans
08.2024 - 07.2026
- Manage incoming calls from providers to assist with reviewing and processing medical referrals and prior-authorizations.
- Manage incoming calls from internal departments.
- Uploads One Time Authorizations for Primary Care Physician Changes.
- Provides authorization for outpatient pre-certification, prior authorization, and post service requests.
- Obtains intake(demographic) information from caller.
- Refers cases requiring clinical review to a nurse reviewer.
- Processes incoming requests from providers for changes needing updating.
- Acts as liaison between medical management and internal departments.
Referral Specialist
Wellcare Health Plans
08.2016 - 12.2023
- Maintained accurate records on in progress and completed departmental project, ensuring full data integrity though process.
- Worked with member advocates to obtain authorization for Long Term Care supportive services.
- Collected and verified completeness of required intake forms for clinical review and coordinated receipt of missing documents.
- Verified insurance benefits and eligibility for procedures prior to authorizing services.
- Assisted clinical and non-clinical staff with troubleshooting and problem resolution.
- Initiated authorization requests for outpatient and inpatient services in accordance with prior authorization list.
- Answered phone calls and messages from member advocates at medical facilities regarding but not limited to authorization intake status, eligibility, scheduling appointments, and coordinating clinical reviews.
- Acted as a subject matter preceptor for operating systems and work process to clinical, non-clinical, and leadership staff.
- Trained staff and new hires.
- Support to the appeals department as needed.
Patient Care Advocate
Medco Health Solutions
03.2004 - 05.2015
- Provided pharmacy benefits to patients, doctor offices, and hospitals.
- Worked with pharmacists to ensure patient counseling and medication compliance.
- Implemented solutions to ensure customer satisfaction.
- Made out-bound calls to schedule specialty medications for delivery in a timely manner.
- Maintained an average 98% quality score.
Education
Bachelor of Science - Healthcare Administration
Stonehill College
Easton, MACertification in Gerontology -
Stonehill College
Easton, MASkills
- Knowledge of HMO's and PPO's
- Managed Care
- Prior Authorizations
- Organization
- HIPAA Compliance
- Active Listening
- Empathy
- Written communication
- Oral communication
- Conflict Resolution
- Patient/family Focused
- Self-motivated
- Team player
- Claims processing
- Referral management
- Authorization procedures
- Customer relationship management
- Data analysis
- Compliance oversight
- Quality assurance
- Training and development
- Effective communication
- Problem solving
- Attention to detail
- Team collaboration
- Time management
- Customer relations
- Employee coaching and mentoring
- Conflict resolution
- Process optimization
- Professional demeanor
- Business intelligence
- Verbal and written communication
- Negotiation and conflict resolution
- Communication skills
- Reporting and documenting
- Active listening
- Interpersonal skills
- Good judgment
- Organizational skills
- Problem resolution
- Decision-making
- Professional and courteous
- Multitasking capacity
- Multitasking Abilities
- Interpersonal communication
- MS office
- Multitasking
- Relationship building
- Time management abilities
- Work Planning and Prioritization
Timeline
Medical Management Rep I
Elevance Health Plans
08.2024 - 07.2026
Referral Specialist
Wellcare Health Plans
08.2016 - 12.2023
Patient Care Advocate
Medco Health Solutions
03.2004 - 05.2015
Bachelor of Science - Healthcare Administration
Stonehill College
Certification in Gerontology -
Stonehill College