JO ANN ALVARADO
San Antonio,TX
Summary
Dedicated and results-driven individual seeking a challenging position where I may utilize my experience, skills, and education to meet employer goals, with the opportunity for internal promotion based on productivity.
Overview
15
15
years of professional experience
Work History
Paraprofessional Secretary III & Teacher
- S Aid Certificate Education Svc Ctr
- Account Executive Training Certificate Texas Workforce Advocates
Supervisor Member Advocate
Community First Health Plan / UHS
02.2022 - 03.2022
- Supervised, assisted, and directed the activities of Member Advocates and all staff within the Member Services Resolution Unit who represent STAR, STAR Kids, CHP, Medicare Advantage, and Commercial members in navigating benefits, services, complaint, and complaint appeals processes and provide education and support to access care and services
- Ensured compliance with the Health Insurance Portability and Accountability Act (HIPAA) related policies regarding all aspects of operations within Member Services
- Provided information to the appeal panels, employer groups and/or regulatory agencies when appropriate
- Assisted in training regarding the Complaint and Appeal process
- Reviewed and approved documentation regarding complaint and complaint appeal cases and acknowledged, logged/entered required information in call tracking module and departmental spreadsheet
- Supervised and monitored all complaints and complaint appeals ensuring timely and accurate resolution based on regulatory and contractual requirement consistent with CFHP policies, and consistent member follow-up
- Created reporting to track, trend and provide information as given by all member or their designee, physicians, center managers and/or nurses and forwarded recommendations to senior management for administrative judgment on any changes needed to improve either the care provided, or the way care is delivered
- Acted as a liaison between all members, service coordination, care management, other departments as needed, and community resources as well
- Attended weekly, bi-weekly and monthly meetings to stay up to date of all policies and procedures
- Reviewed and translated, to Spanish, all documents prior to being sent out to members ensuring accuracy.
Advocate
Community First Health Plan / UHS
08.2021 - 02.2022
- Served as an advocate to assist and/or represent STAR, STAR Kids, CHIP, Medicare Advantage, and Commercial members in navigating benefits, services, complaint, and complaint appeals processes and provide education and support to access services
- Communicated via written correspondence and secure email, as needed
- Assisted members in accessing non-covered services, such as those provided in other social service or community programs
- Additionally, they may be called upon participate in other interdepartmental processes, as needed
- Ensured compliance with the Health Insurance Portability and Accountability Act (HIPAA) related policies regarding all aspects of operations within Member Services
- Maintained documentation on calls regarding benefits, services or complaint and appeal process cases, acknowledging, logging/entering in call tracking module
- This included monitoring the complaint and complaint appeal process ensuring timely resolution in collaboration with the Resolution Unit in Member Services and regulatory agencies consistent to CFHP policy
- Functioned as liaison between STAR members, services coordination, other departments, and community resources
- Ensured and facilitated the delivery of decisions made by Appeals/Fair Hearing panels when appropriate and covered under the plan
- Knowledgeable in all STAR services such as covered services, waiver program, non-capitated services, preventative services, internal authorization processes to list a few but not limited
- Offered options and alternatives, when necessary, by utilizing outside social agencies, including maintaining a community assistance directory
- Handled routing inquiries or complaints regarding benefits and/or services coordination, either by requesting reassignment or by working with the Member, the service Coordination, and other appropriate Staff to facilitate a resolution
- Submitted statistical/data reports to supervisor, manager and/or other departments in need of information on a weekly and monthly basis
- Reviewed the status of open cases weekly with the Resolution Manager, or more often if deemed necessary
- Communicated directly with the STAR member when necessary to obtain information to resolve issue to include documenting in call tracking a summary of conversation
- Responded to STAR member with an appropriate letter regarding status of the inquiry or complaint/appeal consistent with regulations and CFHP policies
- Responsible for translating all correspondence from English to Spanish prior to mailing out
- Performed special projects and other duties as assigned.
Sr. Resolution Representative
Community First Health Plan / UHS
07.2019 - 08.2020
- Served as the Intake person for the Resolution Unit
- Responsible for receiving and assigning all incoming complaints and inquiries from members as well as from state agencies such as HHSC, Maximus, TDI, etc., in a timely manner
- Received and assigned all correspondence whether received by mail or email
- Ensured that all HIPPA requests received, via call center phone logs, were processed in a timely manner
- Processed all primary care physician transfer requests and ensured that all was documented in QNXT (internal program)
- Responsible for call center requests to unlock members’ portal accounts and reset passwords
- Responsible for tracking all assignments in spreadsheets, to include complaints, member portal inquiries, correspondence, walk-ins, reimbursements, SK directory provider requests, and all departmental databases
- Responsible for Complaint and HealthX audits to include all departmental spreadsheets and ensure that they followed Community First Health Plans and state regulations; all the while ensuring that I followed the Health Insurance Portability and Accountability Act (HIPAA)
- Ensured that all complaint files were accurate and complete for internal and state audits
- Responsible for submitting all legal documents to Compliance department for review and ensured all was documented in both QNXT (internal program) and departmental databases
- Responsible for submitting monthly and quarterly complaint reports to other departments as requested
- Responsible for creating all complaint file folders and all departmental filing
- Responsible for gathering and facilitating Departmental Info Huddles, weekly
- Processed HealthX member portal inquiries as assigned by supervisor
- Assisted supervisor with departmental reports
- Assisted in creating Job Aids and Policies for the department as assigned by supervisor
- Responsible for keeping track of all departmental assignments and provided status to supervisor.
Member Service Representative
Community First Health Plan / UHS
01.2017 - 06.2019
- Served as a liaison to members and providers in resolving member services issues
- Provided information to Community First Health Plan members and providers by phone
- Ensured compliance with the Health Insurance Portability and Accountability Act (HIPAA) related policies regarding all aspects of operations within Member Services
- Assisted providers with claims status and member bills
- Assisted members with prescription issues, i.e., prior authorizations, Step Therapy, insurance issues
- Educated members and guide them through website navigation
- Assisted members in obtaining durable medical equipment (DME)
- Assisted members with guidance in obtaining authorization for services or medications
- Maintained a professional relationship with members of other departments as well as internal customers
- Provided supervising staff with assistance in “mentoring” new employees
- Served as a “Tester” for new CFHP System (QNXT)
Outpatient Customer Service Representative Specialist
University Health System
07.2009 - 12.2016
- Responsible for answering incoming telephone calls, appointment scheduling, registration, referral coordination
- Assisted Management team with additional reports/tasks
- Responsible for creating charts for GEMBA boards and presentation
- Served as Healthcare Safety Advocate for 9 months
- Responsible for maintaining call center safety requirements up to par with JACHO Standards
- Responsible for distribution of all faxes and forms received from pharmacy and other entities, medication refills, processing all forms
- Responsible for working on “Bump Lists” – contact patients who cancelled appointments to reschedule
- Audited all Hospital Visits, for providers, in clinic to make certain all documentation was requested prior to patient’s visit
- Provided coverage for Medical Records department as needed
- Assisted Medical Records department with data entry, scanning, indexing and auditing of medical records via OnBase
Director
01.2004 - 01.2007
- Executive supervision of the departmental organization
- Administered and maintained Bylaws
- Promoted programs of growth in enrollment, attendance, and leadership training
- Presided over the regular monthly meetings
- Submitted an annual budget report
- Maintained monthly reports and submitted a written report to the board of directors
- Provided leadership to different departments (total 8)
- Provided leadership training
- Submitted an annual budget request
- Received and reviewed all reports of the various department under my supervision
- Submit a quarterly calendar for group activities to board of directors
- Medical Interpreter Certificate University Health System
Education
Bachelor of Science - Business Management, Healthcare
DeVry University
Diploma - undefined
San Antonio College of Medical & Dental Assistants
Skills
- Leadership: Outstanding ability to influence others to cooperate by use of common sense, personal example, persuasion and encouragement
- Strong interviewing and negotiating skills, persuasive, persistent and resolute
- Strong people person who is highly self-motivated
- Excellent people skills, which include verbal and written communication
- Comfortable with authority and decision makers in crises situations
- Experienced In: Computers - MS Professional Suite (Word, PowerPoint, Excel, Outlook), Internet (E-mail), 65 WPM, 10-Key, Amisys, Emdeon, Web Reports, QNXT, IDX Web & Sunrise, Transcriptions
Timeline
Supervisor Member Advocate
Community First Health Plan / UHS
02.2022 - 03.2022
Advocate
Community First Health Plan / UHS
08.2021 - 02.2022
Sr. Resolution Representative
Community First Health Plan / UHS
07.2019 - 08.2020
Member Service Representative
Community First Health Plan / UHS
01.2017 - 06.2019
Outpatient Customer Service Representative Specialist
University Health System
07.2009 - 12.2016
Director
01.2004 - 01.2007
Paraprofessional Secretary III & Teacher
Bachelor of Science - Business Management, Healthcare
DeVry University
Diploma - undefined
San Antonio College of Medical & Dental Assistants