Gisselle Rodriguez
Miami,FL
Summary
Dedicated and adaptable professional with 12 years of experience in the HealthCare industry with a proactive attitude and fast pace learner. Strong work ethic and effective communication skills. Eager to contribute to a dynamic team and support organizational goals.
Overview
10
10
years of professional experience
Work History
Remote-Community Associate- Bilingual
Florida Blue
Doral, FL
10.2021 - Current
- Retrieve, prioritize, and responds to in-bound referral and consult requests to provide assistance to members with social, benefits, and community resource issues
- Maintain telephonic communication with members to ensure their needs and/or issues are addressed, and conducts follow up calls to ensure members' needs are addressed and resolved
- Also performs member requested research and develops appropriate community resource plan which includes linking and connecting members to community resources or Florida Blue Care Programs
- Facilitate benefit savings for members by proactively educating them on benefit plan impacts and choices available to their Health or Pharmacy plan
- Retrieved and analyzed Care program and Social Service referrals as the initial point of contact for incoming referrals in mailboxes, voicemails, and reports, and distributed to appropriate program for engagement by nursing staff
- Communicated and collaborated with internal and external staff members including initiating referrals to Case Management or Social Services for members interested in program participation.
Care Coordinator
Solis Health Plans
Doral, FL
07.2020 - 10.2021
- Identify service needs, gasps and barriers to treatment to direct resources for the member, as needed
- Coordinate referrals to provider to ensure the provision of behavioral health, medical housing and social supports for members
- Follow up on client's referrals to ensure successful linkage
- Identify, develop and maintain relationships with treating providers, key specialist groups, hospitals and community agencies to leverage resources, share data and address system barriers
- Maintain daily documentation of coordination of care efforts for each member, according to policy.
Case Manager/ Care Coordinator
Aaneel healthcare
Tampa, FL
02.2018 - 03.2020
- Follow up care and care coordination of Medicare members for individual physicians, IPAs and ACOs
- Communicate with members and Monitor Physical, Social and Psychological well-being of members
- Ensure member Medication Compliance and self-management of medication reconciliation
- Perform extensive review of Electronic Health Records
- Prepare, review and assess member care plan for case and disease management
- Communicate with physician's office and other care givers as needed (specialist, lab, diagnostic centers)
- Coordinate with Utilization Management (UM) and Transitional Care Management (TCM) team and facilitate overall patient care and manage update EMR records.
Supervisor - Healthcare Services Operations
MOLINA HEALTHCARE of Florida
Doral, FL
02.2015 - 09.2017
- Supervise the daily operations for the Prior Authorization team of 7 to 15 team members within the Utilization Management Department
- Responsible for ensuring that compliance is met within applicable state program guidelines
- Assisted with data collection used to achieve corporate goals, improve monitoring and reporting in order to meet external requirements
- Prepare and analyze production reports and present to management
- Identify opportunities and create process improvements necessary to facilitate department functions
- Create and prepare correspondence within required timeframe per State and Federal requirements
- Audit the Appeals and Grievance database and the generated denial letters monthly
- Train staff as necessary to ensure consistent performance and adhere to standards
- Supervise staff by communicating job expectations, coaching, counseling, and disciplining employees.
Evening Authorization Supervisor
PREFERRED MEDICAL PLAN
Miami Lakes, FL
06.2014 - 01.2015
- Responsible for the day-to-day oversight of a staff of 6 Prior Authorization Representatives and Leads by ensuring their work activities coordinate with that of management and department by providing expert advice on respective inquiries
- Responsible for setting the work priorities for the team to ensure task completion and performance goals are met such as - Quality, Adherence, Service Level and AHT
- Accountable for coordinating work activities with other supervisors, managers, departments
- Identifying and resolves operational problems using defined processes, expertise, and judgment
- Supervising staff by communicating job expectations, coaching, counseling, and disciplining employees.
Education
40 HR Course - Registered Behavior Technician -
Positive Development
09.2023
High School Diploma -
Miami Senior High School
Miami, FL06-2010
A.S. in Emergency Medical Technician (EMT) Paramedic II -
Fortis College
Skills
- Marketplace guidelines
- AHCA Policies & Procedures
- CMS (Medicare) Policies & Procedures
- GPRO Audit
- CCM
- MDFLOW
- QNXT
- Jiva
- Medical Terminology
- ICD 9 and ICD 10
- HCPC and CPT codes
- NCQA Auditor
- Utilization Management
- Care Coordinator - IP
- Care Coordinator
- Project Management
- Sharepoint
- Long Term Care Regulations
- DME/HH process
- HEDIS Measures
- Health Risk Assessment
- Risk Adjustments
- ECW EHR knowledge
- InterQual knowledge
- MCG Knowledge
- Practice Fusion EHR
Key Qualifications
- Spreadsheet updating
- Training skills
- Documentation Management
- Community Outreach
- Referral Coordination
- Analytical Skills
- Problem-solving aptitude
- Progress evaluations understanding
- Reliability
- Goal Setting
- Administration and management
- Self Motivation
- Problem-solving abilities
- Relationship Building
- Attention to Detail
- Time management abilities
- Continuous Improvement
- Adaptability and Flexibility
- Multitasking
- Volunteer Coordination
- Decision-Making
- Task Prioritization
- Organizational Skills
- Written Communication
- Chronic Disease Management
- Team building
- Interpersonal Skills
Languages
English
Professional
Spanish
Professional
Volunteer work
- Hands on Hands - school painting - July 2015
- American Cancer Society’s Making Strides Against Breast Cancer - Oct 2021
- Consortium of Florida Education Foundations: Spirit of Giving Network on Saturday, July 30th for their Annual Back to School PBC event where over 10,000 students (Grades K-12) in Palm Beach County - July 2022
- Marlins and Farm Share to distribute food to 500 additional families - Aug 2022, July 2023 and Aug 2023
- Global Empowerment Mission(GEM) to assemble Family Necessity Kits for people impacted by Hurricane Ian - Oct 2022
- National Day of Service - Volunteer Opportunity with Camillus House - Sept 11th, 2023
References
References available upon request.
Timeline
Remote-Community Associate- Bilingual
Florida Blue
10.2021 - Current
Care Coordinator
Solis Health Plans
07.2020 - 10.2021
Case Manager/ Care Coordinator
Aaneel healthcare
02.2018 - 03.2020
Supervisor - Healthcare Services Operations
MOLINA HEALTHCARE of Florida
02.2015 - 09.2017
Evening Authorization Supervisor
PREFERRED MEDICAL PLAN
06.2014 - 01.2015
40 HR Course - Registered Behavior Technician -
Positive Development
High School Diploma -
Miami Senior High School
A.S. in Emergency Medical Technician (EMT) Paramedic II -
Fortis College
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