Johanna Lalondriz
Philadelphia,PA
Summary
To secure a position that would utilize and expand my education and experience to strengthen a facility's operations, that seeks and rewards result. Good conflict mediation and multitasking abilities.
Overview
13
13
years of professional experience
1
1
Certification
Work History
Grievance Appeals Specialist
EmblemHealth
Albany, New York
04.2024 - Current
- Conduct thorough investigation of member and provider correspondence by analyzing all the issues involved and obtaining responses and information from internal and external entities.
- Investigated grievances by analyzing case details and relevant regulations.
- Coordinated with internal teams to resolve complex grievances effectively.
- Prepare written responses to all member and provider correspondence that appropriately address each complainant's issues and are structurally accurate.
- Monitor daily and weekly pending reports and personal worklists, ensuring internal and regulatory timeframes are met.
- Follow-up with responsible departments delegated entities to ensure compliance.
- Comprehensively review and evaluate appeal and grievance request to indentify and classify member and provider appeals. Determine eligibility, benefits, and prior activity related to the claims, payment or service in question.
- Assist with triaging cases by reviewing all incoming grievances and appeals to determine the nature of the issue. Assign cases to the appropriate specialist in Compliant Appeals and Grievances (CAG) and identify any cases related to Department Financial Services (DFS) ERROR. Ensure duplicate cases are void. Prioritize Better Business Bureau (BBB), Attorney General cases and Reopeners Accordingly.
Intake Care Specialist
EmblemHealth
Albany, NY
07.2022 - 04.2024
- Review documents for accuracy for prior authorization case creation for both phone and fax in a timely manner.
- Responsible for the execution of the non-clinical aspects of the Utilization Management by ensuring accurate information is entered on cases, for example verify member eligibility and provider network status
- Provide coverage, support to question in a fax support chat.
- Responsible for creating cases for Inpatient/Outpatient/Office/PAC services and send for nurse review for both phone and fax
- Create and approve Inpatient/ future maternity cases
- Made outbound calls to providers to obtain information necessary to create or update authorization.
- Answered telephone calls to give information to callers, or transfer calls to delegated agent.
Medical Assistant
West Orange Women's care
Orlando, FL
01.2022 - 07.2022
- Assisted with medical scribe, updated care plans, Recorded patient history Administer vaccine
- Collected forms, copied insurance cards and coordinated patient information for billing and insurance processing
- Prior authorization of prescription drug
- Assisted physicians by preparing patients for procedures for example, hysteroscope, colposcopy and small routine including EKGs, phlebotomy, glucose testing
- Performed preliminary physical tests, such as taking blood pressure, weight and temperature, accurately recording results in patient history summary.
Unit Secretary/Patient Care Technician
Lankenau Hospital Labor and Delivery, Main Line Health
Wynnewood, PA
07.2018 - 12.2021
- Answered phone calls to provide assistance, information and medical personnel access to maximize office efficiency
- Updated group medical records and technical library to support smooth office operations
- Compiled physical and digital documents, charts and reports to meet business and patient need
- Conducted patient intake interviews to collect medical information and insurance details
- Executed clerical tasks and assisted with all unit duties as directed
- Provided patient information to facilitate timely admissions and discharges
- Managed unit call reception and routed calls to correct department
- Assisted doctors, nurses and support staff with preparation for and conducting patient procedures
- Supported nurses in daily patient care activities by taking vital signs and documenting patient observations
- Collected lab specimens in adherence with safety protocols for patient tests
- Also phlebotomy and EKG.
Patient Care Technician
Lankenau Hospital Oncology and Heart Attack, Main Line Health
Wynnewood, PA
10.2015 - 07.2018
- Assisted doctors, nurses and support staff with preparation for and conducting patient procedures
- Assisted with patient admission, discharge and transfer to maximize facility efficiency
- Responded to patient alarms and needs-assessment requests to identify course of treatment
- Documented patient intake and dietary requirements, also assisting with feeding and monitoring
- Supported nurses in daily patient care activities by taking vital signs and documenting patient observations
- Collected lab specimens in adherence with safety protocols for patient tests
- Promoted patient satisfaction by assisting with daily living needs such as bathing, dressing, toileting and exercising
- Improved patient care, safety and compliance by partnering with nurses.
Medical Assistant
Lankenau Hospital Electrophysiology, Main Line Health
Wynnewood, PA
08.2012 - 10.2015
- Sterilized instruments and disposed of contaminated supplies in adherence to OSHA regulations
- Interviewed and engaged patients to obtain medical history, chief complaints and vital signs
- Assisted with diagnostic testing by collecting and packaging biological specimens for internal and laboratory analyses
- Prepared prescription refill requests on behalf of physician to prevent lags
- Collected forms, copied insurance cards and coordinated patient information for billing and insurance processing
- Assisted physicians by preparing patients for procedures, including EKGs, phlebotomy, glucose testing and pulmonary function tests
- Performed accurately recording results in patient history summary.
Education
Associate's degree in Medical Assisting -
ASA - The College for Excellence
Brooklyn, NY01.2011
Skills
- Phlebotomy
- Hospital Experience
- Vital Signs
- Epic
- Intake Experience
- Medical Office Experience
- EMR Systems
- Laboratory Procedures
- Medical Records
- Triage
- Experience Administering Injections
- Insurance Verification
- Patient Care
- Microsoft Word
- Athenahealth
- Data entry
- Case investigation
- Written communication
- Grievance resolution
- Attention to detail
- Problem-solving capacity
- Strong leadership
Certification
- Basic Life Support (BLS), 10/2021, 10/2023
- NHA Certified Phlebotomy Technician, 06/2022, 06/2024
- NHA Certified Clinical Medical Assistant, 07/2022, 07/2024
Languages
Spanish, Expert
Timeline
Grievance Appeals Specialist
EmblemHealth
04.2024 - Current
Intake Care Specialist
EmblemHealth
07.2022 - 04.2024
Medical Assistant
West Orange Women's care
01.2022 - 07.2022
Unit Secretary/Patient Care Technician
Lankenau Hospital Labor and Delivery, Main Line Health
07.2018 - 12.2021
Patient Care Technician
Lankenau Hospital Oncology and Heart Attack, Main Line Health
10.2015 - 07.2018
Medical Assistant
Lankenau Hospital Electrophysiology, Main Line Health
08.2012 - 10.2015
Associate's degree in Medical Assisting -
ASA - The College for Excellence