Julio Gruezo
Methuen,Ma
Summary
Accomplished & enthusiastic professional who seeks to maintain a full-time position that offers professional challenges utilizing interpersonal skills, excellent time management, and problem-solving skills. With 16+ years of successful Experience in the health industry and Business Administration, I have solid competencies, am exceptionally organized, have exceptional Experience in customer services, am detail-oriented, self-driven, disciplined, and possess well-developed interpersonal skills with the ability to multi-task and deliver excellent results.
Overview
10
10
years of professional experience
Work History
Transportation / Member Services Representative
Commonwealth Care Alliance
06.2018 - 12.2023
- Respond to and answer all member and provider inquiries in a courteous, responsive, comprehensive, effective, and accurate manner following all departmental and organizational policies and procedures
- Participate as part of a team conducting and/or supporting outreach to members regarding benefits and eligibility requirements
- Thoroughly document all member-related and prospective member interactions into CCA database for purpose of accurate tracking and analysis
- Coordinate with various roles within CCA and its interdisciplinary and/or primary care partners to ensure external and internal customer requests and questions are handled appropriately and in a timely manner
- Provide translation and interpretation when requested/approved by supervisor.
- Contributed to team sales goals by upselling products and services to customers.
Provider Services Representative
Commonwealth Care Alliance
01.2020 - 05.2023
- Interface with CCA's provider departments including credentialing, PDM, Provider Relations and Contracting
- Answer critical incoming phone calls from providers and respond to inquiries, concerns and questions about coverage, benefits, eligibility and authorization status
- Navigate through multiple, complex systems and screens while maintaining caller engagement
- Document all critical information in the appropriate screen and system
- Submit providers' verbal requests for prior authorization and educate providers on PA review process and required documentation
- Assist providers in resolving claims denials and navigate processes to understand source of denial including Claims Department Registrar, Outgoing Referrals, and Retro Authorization process
- Communicate rules Continuity of Care to provider and ensure it is applied during coverage determination inquiries.
CCPO-Clinical Research Coordinator
Massachusetts General Hospital
11.2015 - 05.2017
- Monitors and reports adverse events as required by institutional/federal regulations; coordinates and procures investigational drug supplies and prepares submission of protocol revisions and safety reports to the IRB
- Submits all Institutional Review Board (IRB) FDA, and Vendors documentations
- Acts as liaison between Sponsor, and Principal Investigators
- Monitors and evaluates protocol compliance, manages data collection via chart abstraction and submits data in timely fashion
- Works with clinicians to screen subjects for suitability of research study participation
- Develops and implements recruitment strategies.
Urgent Escalations- Member Service Specialist
Dell Inc., Health Connector
10.2013 - 11.2015
- Responsible for directing key components in applying policies, regulations, and standards; reviewing and certifying new applicants for the Massachusetts Health Connector
- In addition, oversees operational reporting, quality assurance of Commonwealth Care operations
- Implements, and operates Health Insurance Exchanges that support consumers, employers, employees, brokers, navigators and all stakeholders
- Connecting individuals, businesses, and families with insurance products
- Manage client business process and identify areas for continued improvement; may support more than one client team based on project scope and complexity
- Ensure that the team delivers quality service to our clients, accuracy and time standards are consistently met
- Keep the team updated on client's Insurance plans and benefits regulations by testing their knowledge and through training and development.
Education
Bachelor of Science in Business Administration -
Hesser College
Manchester, NH12.2008
Skills
- CACTUS
- EZ-CAP
- EZ Net
- Navitus
- PaySpan
- MMIS (Medicaid Management Information System)
- Optum
- Epic
- Oracle
- TAO
- RAVE
- Meditech
- Excel
- PowerPoint
- Microsoft Word
- Microsoft Project
- Outlook
- RE@LM (Trimble)
- Buy Smart
- SharePoint
- Vendor Master Records Management
- Yardi (basic)
- Customer Support
- Idea Development and Brainstorming
Accomplishments
- Successfully completed the Provider Service training, Pharmacy, Dental, Claims, Provider Relations, Credentialing, Contracting, PDM.
- Successfully completed the member Service training, Pharmacy, Dental, vision for One Care and SCO members.
- Successfully completed The Transportation member services on the Circulation Platform.
- Responsible for directing key components of Commonwealth Care operations on behalf of the Massachusetts Health Connector and oversees operational reporting, quality assurance.
- Implements, and operates Health Insurance Exchanges that support consumers, employers, employees, brokers, navigators and all stakeholders, connecting individuals, businesses, and families with insurance products.
Spanish speaker
I can read and write professionally since my first language is Spanish.
Languages
Spanish
Full Professional
Timeline
Provider Services Representative
Commonwealth Care Alliance
01.2020 - 05.2023
Transportation / Member Services Representative
Commonwealth Care Alliance
06.2018 - 12.2023
CCPO-Clinical Research Coordinator
Massachusetts General Hospital
11.2015 - 05.2017
Urgent Escalations- Member Service Specialist
Dell Inc., Health Connector
10.2013 - 11.2015
Bachelor of Science in Business Administration -
Hesser College