JENNIFER CORTEZ
Chino,CA
Summary
Offering successful career history of 12 years. Strong verbal and written communication skills (English and Spanish)
Strong collaboration skills to thrive in fast-paced, high-stress environments. 12 years of successful professional customer service experience. Adaptable within an ever-changing work environment. Demonstrate ability to prioritize multiple projects in conjunction with daily tasks. Expert proficiency with Microsoft Office applications, including: Word, Excel and PowerPoint. Critical thinking and problem solving. Quick learner and self motivated. Expert of medical terminology and Certified Facilitator.
Overview
9
9
years of professional experience
Work History
Pharmacy Technician
Department of Health Services (LA County)
Los Angeles , CA
2023.04 - Current
- Coordinated resolutions for issues and appealed denied authorizations.
- Performed detailed medical reviews of prior authorization request, following established criteria and protocols.
- Applied knowledge of Medicare, Medicaid and third-party payer requirements utilizing on-line eligibility systems to verify patient coverage and policy limitations.
- Notified ordering providers of denied authorizations.
- Answered telephones to respond to questions or requests.
- Entered prescription information into computer databases.
- Assisted pharmacist with clearing high volume of prescriptions and responded to customer questions.
- Completing Inpatient and Outpatient Prior Authorizations.
- Completing request's on cover my meds.
Appeals and Grievances Coordinator
Aston Carter Agency (SCAN Health Plan)
Woodland Hills , CA
2022.06 - 2023.03
- Identified reasons behind denied claims and worked closely with insurance carriers to promote resolutions.
- Monitored reports to identify claims issues and worked with adjusters to resolve problems.
- Acted as intermediary between insurance companies and customers by researching and assessing information to determine claim validity.
- Assisted claimants, providers and clients with problems or questions regarding claims.
- Examined claims, records and procedures to grant approval of coverage.
- Processed claims for payment or forwarded to appropriate personnel for further investigation.
- Familiar with IKA, Genesys, Medhok and Maximus.
- Contacting provider and medical groups.
- Claims Examiner with Medicare and HMO
- Adjudicating both professional and facility type of claims
- Working with auditing and appeals
- Effectively interpreting provider contract language and provisions
- Medical terminology, ICD9, ICD 10
- Extensive HMO knowledge
- Intermediate/Advanced Proficiencies in MS Excel, Access
- Appeals experience
- Excellent grammatical and letter writing skills; in adherence to regulatory guidelines
- Proven excellent analytic skills
- Flexible, self-starter, team player
- Ability to work independently and solve moderately complex issues with limited supervision.
Appeals and Grievances Coordinator
Optum, UnitedHealth Group
Costa Mesa , CA
2016.06 - 2022.05
- Analyze/research/understand how a claim was processed and why it is under dispute
- Identify/obtain all necessary medical records for any appeal which requires a clinical review
- Leverage appropriate resources to obtain all information relevant to the claim
- Proactively identifies solutions to non-standard cases.
- Solves moderately complex problems on own.
- Ensures members receive exceptional customer service.
- Plans, prioritizes, organizes and completes work to meet operational performance metrics.
- Document and communicate final determination of appeals using appropriate templates, communication processes in a timely manner to all applicable parties
- Understand and adhere to applicable federal/state laws and regulations
- Maintain confidentiality of member appeals information per HIPPA regulations
- Understand and adhere to applicable documentation handling policies and regulations
Facilitator/Lead Pharmacy Technician
Optum, UnitedHealth Group
Costa Mesa , CA
2016.01 - 2016.06
- Teaching Contractors how to do Prior Authorizations.
- Going over powerpoint presentations and explaining step by step.
- Training 24 contractors.
- Developed training materials, manuals, procedures and visual aids to effectively achieve organizational goals.
- Identified and communicated to management regarding areas needing additional training.
- Conducted training needs assessments to identify individuals' current level of skill compared to required competency for position.
- Evaluated and communicated trainee participation and performance in reports to management.
- Awarded certificates to employees who completed training to recognize accomplishments, boosting motivation and retention.
- Delegated daily tasks to team members to optimize group productivity.
- Monitored team progress and enforced deadlines.
- Organized and prioritized incoming work orders and optimized team workflows and resources to handle dynamic demands.
- Recruited and trained new employees to meet job requirements.
Prior Authorization Mail/Outreach Coordinator
Optum, UnitedHealth Group
Costa Mesa , CA
2015.11 - 2016.01
- Getting mail from member's who mailed there prior authorizations.
- Entering everything from scratch and determine if case will be approve or not.
- Performed detailed medical reviews of prior authorization request, following established criteria and protocols.
- Contacted insurance carriers to obtain authorizations, notifications and pre-certifications for patients.
- Contacted insurance companies to obtain necessary pre authorizations needed for upcoming tests and procedures.
- Provided accurate information to all parties, including patients, insurance providers, healthcare staff and office personnel by using effective written and verbal communication skills.
- Coordinated resolutions for issues and appealed denied authorizations.
- Notified ordering providers of denied authorizations.
- Calling members about decision.
Prior Authorization Coordinator
Optum, UnitedHealth Group
Costa Mesa , CA
2014.07 - 2015.11
- Applied knowledge of Medicare, Medicaid and third-party payer requirements utilizing on-line eligibility systems to verify patient coverage and policy limitations.
- Completed relevant insurance and other claim forms.
- Compiled and coded patient information or data in appropriate computer system.
- Answered telephones and directed calls to appropriate medical or administrative staff.
- Adhered to HIPAA requirements to safeguard patient confidentiality.
- Used PAS to input claim, prior authorization and other important medical data into system.
- Called members to let them know about decision.
- Check formulary if member met criteria.
- Obtain insurance prior authorization for patient prescriptions, treatments, services, or procedures and re-authorization for additional units including performing any retro-authorization requests as allowed by payers; appeal prior authorization denials and help facilitate peer-to-peer reviews as needed. Appropriately document authorization details in the patient’s medical record including notifying clinical staff of benefit limitations and authorization status.
- Monitor pre-auth denials for trends and provider documentation issues, and escalate to Lead or Supervisor as appropriate
- Pre-screen appointment schedules and work 1-2 weeks out with provider schedules along with checking daily add-ons. Meet or exceed productivity expectations after orientation period to ensure requests are being processed timely.
- Assist Operation teams with processing externally referred patients
- Ensure registration and insurance are accurately loaded into system, and make any necessary corrections
- Escalate any issues or concerns to the appropriate department or manager as necessary
- Maintain strictest confidentiality
- Work on assigned projects as needed
- Perform other duties as assigned
Medical Staff Coordinator
Chino Valley Medical Center
Pomona , CA
2014.04 - 2014.11
- Collaborated with multi-disciplinary staff to improve overall patient care and response times
- Resolved conflicts promptly among physicians, nurses and other healthcare employees to keep workflow on task
- Educated pharmacy assistants on medication assistance, ordering and insurance issues
- Implemented new hire training to further develop skills and initiate discussions on task prioritization
- Trained pharmacy interns and newly hired technicians
- Supervised team of pharmacy technicians, interns and support staff.
Education
Bachelor’s - Business Administration Human Resources and management
California Polytechnic State University
AA - Social & Behavioral Science
Mt San Antonio College
AA - Business
Mt San Antonio College
ADT - Business Administration
Mt San Antonio College, Optum Rx
Certified Facilitator -
United Health Group
Pharmacy Technician License -
American Career College
Skills
- Customer Service
- Microsoft Office
- Team Management and Supervision
- Decision Making
- Multitasking and Organization
- Remote Work Coordination
- Confidence and Drive
- Honesty and Integrity
- Spanish Fluency
- Work from Home
- Supervision & Leadership
- Attention to Detail
- Data Quality
- Data Analysis
- Clear and Concise Communication
- Computer Skills
Timeline
Pharmacy Technician
Department of Health Services (LA County)
2023.04 - Current
Appeals and Grievances Coordinator
Aston Carter Agency (SCAN Health Plan)
2022.06 - 2023.03
Appeals and Grievances Coordinator
Optum, UnitedHealth Group
2016.06 - 2022.05
Facilitator/Lead Pharmacy Technician
Optum, UnitedHealth Group
2016.01 - 2016.06
Prior Authorization Mail/Outreach Coordinator
Optum, UnitedHealth Group
2015.11 - 2016.01
Prior Authorization Coordinator
Optum, UnitedHealth Group
2014.07 - 2015.11
Medical Staff Coordinator
Chino Valley Medical Center
2014.04 - 2014.11
Bachelor’s - Business Administration Human Resources and management
California Polytechnic State University
AA - Social & Behavioral Science
Mt San Antonio College
AA - Business
Mt San Antonio College
ADT - Business Administration
Mt San Antonio College, Optum Rx
Certified Facilitator -
United Health Group
Pharmacy Technician License -
American Career College
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