Isabel T. Medina
San Antonio,USA
Summary
I have 9 years of claims experience. I provide valuable contributions through my attention to detail, hardworking nature, and positive attitude. I am self-sufficient, courteous, and a committed team player. In my role, I resolve complex and urgent claims issues daily while maintaining a high level of accuracy. I assist with team questions, concerns, and claim policies, along with collaborating with business partners to discuss new policies and process improvement plans. Overall, I am extremely energetic employee and truly passionate about my work.
Overview
23
23
years of professional experience
Work History
GBD Ops Analyst
Wellpoint AKA Amerigroup
02.2016 - Current
- Responsible coordinating the resolution of claims issues by actively researching and analyzing systems and processes that span across multiple operational areas.
- Investigate and facilitate the resolution of Medicaid claims issues for Wellpoint, Children’s Health Plan, and Amerigroup health plans, including incorrectly paid claims, by working with multiple operational areas and health plans and analyzing the systems and processes involved in member enrollment, provider information management, benefits configuration and/or claims processing.
- Identify the interdependencies of the resolution of claims errors on other activities within operations.
- Assist in the reviews of state or federal complaints related to claims.
- Coordinate the efforts of several internal departments to determine appropriate resolution of issues within strict timelines.
- Interact with network providers and health plans regularly to manage customer expectations, communicate risks and status updates, and ensure issues are fully resolved.
- Perform claims and trend analysis, ensures supporting documentation is accurate and obtains necessary approvals to close out claims issues.
- Recommend new or modified processes and procedures to reduce claims errors, taking into consideration business requirements and system limitations.
- Perform user acceptance testing to ensure new contracts are loaded correctly and system modifications are accurate.
Surgery Verification Coordinator
Christus Santa Rosa Physician Ambulatory Surgery Center
03.2015 - 01.2016
- Verify all insurance benefits in high volume setting and advice guarantor of any expected expense in order to maximize cash collections and minimize bad debt expense, while maintaining the integrity of patient accounting and maintaining good customer relations.
- Collects, verifies and enters demographics and insurance information into the system on new and established patient accounts as requested directly or indirectly by receipt of scheduled appointments.
- Obtains insurance information necessary for various surgical procedures.
- Verifies patient eligibility and benefit package information via phone or online resources.
- Advises patients and clinical staff regarding patient’s financial responsibilities and explains co-payment collection, deductibles and the billing process based on the patients financial status classification.
- Obtains needed information from PCP and HMO payers to initiate managed care authorizations/pre-certification allowing no more than 48 hours for completion.
- Make appropriate notations in the system in regard to actions taken and insurance verification and authorizations.
- Review scheduling reports to ensure all patients listed are worked prior to patient appointment date.
- Work closely with all managers regarding issues with insurance.
- Advice supervisor of any pending issues or possible issues.
Surgery pre-authorization Coordinator
Northeast Orthopaedic & Sport Medicine
07.2012 - 09.2014
- Verify patients’ insurance benefits
- Obtain surgery authorizations
- Obtain referral from PCP office on HMO insurances
- Obtain physical therapy and EMG referrals from insurance company or PCP office
- Follow up to confirm patients were scheduled for physical therapy and EMG
- Schedule patients a follow appointment with the doctor after studies have been completed
Surgery Scheduler
PRMA of South Texas
04.2012 - 06.2012
- Schedule patients for surgery
- Verify patients’ insurance benefits and obtain authorization
- Write pre-determination letters and follow up weekly with insurance companies for status
- Advises patients and clinical staff regarding patient’s financial responsibilities and explains co-payment collection, deductibles and the billing process based on the patient’s financial status classification
Clinical Coordinator
Sonterra Medical Management Group
05.2005 - 04.2012
- Assist physician & PA in clinic assure it runs smoothly and on time
- Triage phone calls
- Complete disability forms
- Call in medication recommended by physician
- Schedules patient for surgery and advises patients of pre-surgical requirements to include laboratory orders and /or x-rays.
- Entered orders and medication into EMR
- Entered charges for patient visits, surgeries, and hospital consults
- Obtain referrals from other health care providers/insurance carriers
- Submit pre-authorization for worker compensation
- Obtain authorization for all studies being ordered by physician
- Obtain authorization for medication refills
- Schedule consultations, x-rays, lab tests, physical therapy, MRI's, CT scans as recommended by the physician
- Schedule surgeries with the hospital and anesthesia
- Verify insurance benefits when needed
- Assist patients/visitors to determine nature of request or problem
- Proofread/correct claims prior to submitting to insurance companies
- Appeal denied claims for payment purposes
- Proof clinical office notes
- Oversees the day-to-day clinic activities and schedule to reduce patient wait times and reduce overtime expenses.
Accounts Receivable
HealthSouth San Antonio Surgery Center
11.2004 - 04.2005
- Record all incoming mail-in payment and denial into excel
- Review and verify all payments and/or contractual negotiation agreements
- Review and prepare appeals on denials received from insurance carriers
- Review outstanding accounts receivable daily
- Communicated with insurance carriers and/or patients regarding outstanding balances
- Documents all contacts with carriers and or patients regarding outstanding balances
- Obtained surgery pre-certification when needed
- Assist front office including answering phones, filing, making charts, and scheduling
- Verify patient co-pay, co-insurance, and deductible with our contract prior to surgery for collection at time of service
- Take necessary steps to obtain payment
- Maintains patient confidentiality
- Sort mail
Accounts Receivable Specialist
The Hand Center
06.2002 - 11.2004
- Review patient demographic entered billing system
- Post all incoming mail-in payment into the billing system
- Review and verify all payments and/or contractual negotiation agreements
- Review and prepare appeals on denials received from insurance carriers
- Review outstanding accounts receivable daily
- Communicated with insurance carriers and/or patients regarding outstanding balances
- Review and prepare refunds due to patient and insurance carriers
- Documents all contacts with carriers and or patients regarding outstanding balances
- Take necessary steps to obtain payment
- Maintains patient confidentiality
- Communicated and works closely with collection/insurance departments regarding outstanding balance
- Pick-up and sort mail
- Electronically send claims to carriers and audit reports for rejected claims
- Prepares paper claim as needed and mail out with required documentation as requested by insurance carrier
- Prepares Physician Liens when necessary
- Obtained surgery pre-certification when needed
- Checks the daily patient schedule and review all patient account for outstanding balance
- Assist front office including answering phones, filing and scheduling
- Assist with charges and payment entry of daily encounters
- ICD-9 AND CPT coding
Education
High School Diploma -
Brackenridge High School
San Antonio, TX05.1998
Principal of Accounting - Introduction to Business
St. Phillips College
San Antonio, TX08.1998
Skills
- Strong organizational ability
- Multi-task oriented
- Problem solving
- Fast accurate data entry
- Complex Problem-solving
- Attention to detail
- Self-starter
- Team player
- Excellent customer service
- Ten Key by touch
- 60 WPM
- Decision-making
- Excel proficiency
- Data research and validation
- Analytical thinking
- Root-cause analysis
- Documentation and reporting
- Regulatory compliance
- Deadline adherence
- Issue identification
- Verbal and written communication
- Critical thinking
- Microsoft office
- MS Excel
Timeline
GBD Ops Analyst
Wellpoint AKA Amerigroup
02.2016 - Current
Surgery Verification Coordinator
Christus Santa Rosa Physician Ambulatory Surgery Center
03.2015 - 01.2016
Surgery pre-authorization Coordinator
Northeast Orthopaedic & Sport Medicine
07.2012 - 09.2014
Surgery Scheduler
PRMA of South Texas
04.2012 - 06.2012
Clinical Coordinator
Sonterra Medical Management Group
05.2005 - 04.2012
Accounts Receivable
HealthSouth San Antonio Surgery Center
11.2004 - 04.2005
Accounts Receivable Specialist
The Hand Center
06.2002 - 11.2004
Principal of Accounting - Introduction to Business
St. Phillips College
High School Diploma -
Brackenridge High School
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