Joanna Rodriguez
Phoenix,AZ
Summary
To seek and maintain full-time position that offers professional challenges utilizing interpersonal skills, excellent time management and problem-solving skills.
Overview
16
16
years of professional experience
Work History
Clinical Review Processor/Clinical Appeals Liaison
Oscar Health Insurance
03.2019 - 10.2022
- Intake, assessment, coordination of appeals, and liaising with several external agencies including state regulators and other third parties responsible for health plan administration and Oscar's internal Clinical Review Team
- Assess eligibility of appeals, gathered case documentation and medical records to ensure that requested or established timeframe requirements are met
- Outreach to providers for medical records and to members as needed to gather details relevant to appeals
- Coordinated with upper level management such as Medical Directors with level 1, 2 and 3 appeals in order to represent members' appeal accurately
- Advocated for members to ensure that members understood their appeal rights and had clear understanding of appeal process.
- Ability to read, interprets, and analyzes documents such as reports, guidelines, plan documents and summary plan descriptions.
- Responsible for training for all new Appeals Specialists on all Regulations and Operations
Customer Service Representative/Insurace Specialist
McKesson Health Solutions
11.2017 - 05.2018
- Verifies insurance benefits for new patient referrals
- Re-verifies insurance benefits for existing patients
- Reviews all medical documentation against medical policy and initiates pre-determination, pre-certification, and authorizations
- Follow-up on pending pre-certifications and/or pre-determinations
- Completes special projects as assigned
- Performs other job related duties as assigned
- Take inbound calls from patients to locate treatment providers.
Collections Customer Service Representative
Toyota Financial Services
08.2016 - 09.2017
- Retrieving payment history from available systems and clearly communicating the status to the customer
- Analyzing account characteristics and working with customers to resolve their issues, persuading them to bring their account current
- Utilizing all collection tools available to maintain delinquencies and losses at or below
- Customer Service Center objectives.
Reimbursement Insurance Specialist
McKesson Healthcare
07.2014 - 07.2016
- Contact payers to verify patient eligibility and product specific coverage information
- Provide claims assistance, including billing and coding instructions, to physicians and/or office staff
- Provide accurate and timely follow-up to all reimbursement inquires in accordance with program guidelines
- Obtain and compile payer specific information for reimbursement database.
Claims Benefit Specialist
Aetna
02.2010 - 10.2013
- Claims processing for Mercy Care Plan and Illinois Integrated Plan
- Analyze and approve routine claims that cannot be auto adjudicated
- Coordinate responses for routine phone inquiries and written correspondence related to claim processing issues
- Facilitate training when considered topic subject matter expert.
Claims Representative
Health Choice of Arizona
10.2008 - 01.2010
- Responsible for adjudicating incoming Institutional and Physician claims
- Give information regarding claims payment.
Claims Representative
Blue Cross Blue Shield of Arizona
05.2006 - 02.2008
- Process Institutional and Physician claims
- Explain to subscribers and group representatives contract benefits, and changes in coverage
- Give information regarding claims payment
- Conduct research and updates on a current daily basis.
Skills
- Proficient in Microsoft Word, Excel, Power Point, Outlook, Multiple Health Insurance Websites; Excellent Customer Service; Strong Interpersonal Skills
- Authorization Input
- Benefits Verifications
- Regulatory Documentation
- Insurance Authorizations
Timeline
Clinical Review Processor/Clinical Appeals Liaison
Oscar Health Insurance
03.2019 - 10.2022
Customer Service Representative/Insurace Specialist
McKesson Health Solutions
11.2017 - 05.2018
Collections Customer Service Representative
Toyota Financial Services
08.2016 - 09.2017
Reimbursement Insurance Specialist
McKesson Healthcare
07.2014 - 07.2016
Claims Benefit Specialist
Aetna
02.2010 - 10.2013
Claims Representative
Health Choice of Arizona
10.2008 - 01.2010
Claims Representative
Blue Cross Blue Shield of Arizona
05.2006 - 02.2008