Isabel Bernal
Albuquerque
Summary
Experienced with appeals processing and regulatory compliance. Utilizes analytical skills and effective communication to facilitate dispute resolution. Knowledge of workflow optimization to improve efficiency and resolution times.
Overview
14
14
years of professional experience
Work History
Member Appeals Coordinator
Medicare and MAXIMUS
10.2022 - Current
- As a Medicare and MAXIMUS, Member Appeals Coordinator my responsibilities are assuring that all compliance timelines are met.
- I’m a mentor a resource and a team lead in addressing Medicare/MAXIMUS member appeals.
- I work directly with the Appeals Medicare Supervisor to ensure daily Medicare compliance for our star rating expectations.
- I also monitor all incoming MAXIMUS decisions and acknowledgements and track compliance MAXIMUS cases.
- I review Team letters on a daily for quality expectations.
- In my role I also had the opportunity to participate in the in person 2024 Medicare full plan audit and I worked directly with management creating Medicare file audits to ensure cases were completed for file review.
Office Administrator
New Mexico Mutual
03.2020 - 10.2022
- As the office administrator my daily duties included: maintaining daily calendars, setting up appointments for our Workman’s Compensation customers and assisted the Claims, Audit and Billing Department as a Spanish interpreter.
Appeals Coordinator
Presbyterian Health Plan
03.2015 - 03.2019
- I was responsible for the daily coordination of the Medicaid and Medicare coordination of the assigned Appeals.
- Assuring that all the compliance timelines were met.
- I was also a mentor, a resource and a team lead in addressing Medicare/Medicaid member appeals.
- I also provided feedback and improvement recommendations to appropriate quality committees on analysis and trending appeals data and was responsible of identifying of trends and meeting goals.
Medicare and Medicare Appeals Research Specialist
Presbyterian Health Plan
08.2012 - 03.2015
- My role as a Medicare/Medicaid Research Specialist consisted of responding to verbal and written appeals that involved complexed matters.
- I was responsible for performing comprehensive research to clarify facts and circumstances.
- I identified the root cause of an issue such as resolution and prior authorization denials, claim denials and benefit coverage issues.
- I made the initial decision regarding resolution and appeal based on my completed research.
- I was also a member advocate in each case, comparing the appellants issue with the organizations’ documented facts.
Customer Service Walk in Representative
Presbyterian Health Plan
04.2011 - 08.2012
- As a patient financial representative my daily duties were to assist our walk in patients with setting up payment plans for any hospital billing and PMG billing.
- I also processed payments and posted them to their accounts as well as assisted with the financial assistance applications.
- I was also a back up for the overflow of the incoming calls for out Patient Financial Customer Service Department.
Education
High School Diploma -
Ysleta High School
El Paso, Texas05.1998
Skills
- Strong interpersonal and conflict resolution
- Problem Solving
- Superior verbal and written communication skills
- Team Player
- Insurance regulations
- Confidentiality
- HIPAA compliance
- Insurance policies
- Teamwork and collaboration
- Time management
- Attention to detail
- Multitasking skills
- Listening skills
- Reliability
- Critical thinking
- Organizational skills
- Team collaboration
Languages
Spanish
Timeline
Member Appeals Coordinator
Medicare and MAXIMUS
10.2022 - Current
Office Administrator
New Mexico Mutual
03.2020 - 10.2022
Appeals Coordinator
Presbyterian Health Plan
03.2015 - 03.2019
Medicare and Medicare Appeals Research Specialist
Presbyterian Health Plan
08.2012 - 03.2015
Customer Service Walk in Representative
Presbyterian Health Plan
04.2011 - 08.2012
High School Diploma -
Ysleta High School
Similar Profiles
Leigh CutrerLeigh Cutrer
Manager at Maximus Call Center (1-800-Medicare)Manager at Maximus Call Center (1-800-Medicare)
Andrew K. KeenanAndrew K. Keenan
Health Insurance Specialist at Department of Health and Human Service / Centers for Medicare and Medicaid Services / Center for Medicare/ Performance-Based Payment Policy Group (P3)Health Insurance Specialist at Department of Health and Human Service / Centers for Medicare and Medicaid Services / Center for Medicare/ Performance-Based Payment Policy Group (P3)
Meghan GogginMeghan Goggin
Medicare Sales Agent at Medicare Health AdvisersMedicare Sales Agent at Medicare Health Advisers
Yasmenah AliedehYasmenah Aliedeh
Student Assistant at Dona Ana Community CollegeStudent Assistant at Dona Ana Community College
Cynthia GutierrezCynthia Gutierrez
Assistant General Manager at Hudson News GroupAssistant General Manager at Hudson News Group