Misleydis Pena
Miami,USA
Summary
Professional environment where I can utilize my vast healthcare experience, and medical insurance knowledge to further pursue my career.
Overview
22
22
years of professional experience
Work History
Senior Customer Service Specialist
Provider Network Solutions
05.2024 - Current
- Answer calls from providers to verify eligibility and provide them with claims payment status.
- Search for members navigating through the TPA System and main health plan sites in order to check on member eligibility.
- Read and comprehend paid and denied claims and explain denial codes.
- Educate providers on the appeal/claim submission process and provider portal use.
- Demonstrate professional etiquette and courtesy when interacting with providers.
- Accurately and comprehensively documents all communications from providers based on organization policies and procedures through investigative research to create internal PDR’s. internal open tickets.
- Assist the Claim Department by entering appeals in the TPA System.
- Assist the health plan by providing participating physicians information within the network per line of business (LOB).
- Assist the other customer service representatives on escalated issues.
- Support coverage for mailroom
- Support coverage for EDI Specialist
- Process daily pending eligibility review for claims department workflow.
- Generate provider letters weekly for rejected claims.
- Create refund letters and upload supporting documents in the claims processing system
- Review deductibles and out of pockets accumulators’ queue for claims department
- Distribute faxes that are received daily to all departments.
- Performs other duties as assigned by Management.
- Assist daily of incoming mail in the mailroom for disputes, created records of the disputes including all gathered documentation for processing
Service, Team Lead
Account Technologies US
01.2022 - 01.2023
- Company Overview: Account Technologies US is a subsidiary of Account Technologies based in the United Kingdom. Account Tech Provides financial solutions to UK and US customers, supporting a large number of clients needing financial assistance.
- Hire, provide training and follow employees' paths within the company protocols.
- Provide feedback and monthly reviews to ensure top performance.
- Introduced strategic launch plans, processes, and training.
- Created score cards and ensured all employees were passing QA by over 85%.
- Responsible for the daily operations of 5+ employees.
- Monitored compliance.
- Mentored rising stars, who would grow into core leadership positions including Team Leader, Quality Assurance and Director roles.
- Provided continual process improvement including all processes and procedures.
- Coached technical support through SLA changes to support metrics development.
- Analyze representative performance data as well as customer interaction results to manage team's performance and to make improvements to the servicing model.
- Developed and manage call quality and order accuracy programs and processes and developed call handling guidelines and scripting.
- Drive changes necessary to improve the operating efficiency and organizational effectiveness of the Service Excellence team.
Customer Service Representative
Bupa/Blue Cross Blue Shield Global
01.2014 - 01.2020
- Manage claim requests, notification and pre-authorization questions via email and phone from members and providers within given deadlines and service objectives.
- Send a letter of authorization or denial and explanation of benefits depending on the treatment evaluation.
- Enter notes for every conversation, email and decision in the system so that it is available Company-wide.
- Handle calls and emails from Business Partners’, Brokers, Members and Service Centers within department expectations to meet service expectations.
- Resolves questions and issues concerning delays in new business application delays.
- Delivers personalized customer care to Brokers and policyholders by resolving issues personally, regardless of the question or issue, calls back with information or resolution within set deadlines, exceeding customer expectations.
- Handle questions and claims issues for policy.
- Able to identify an incorrect processed claim (i.e. incorrect case handling, payments and diagnosis) and able to cross reference claims among the system.
- Assist policy holders visiting Miami.
- Handles requests for proof of insurance.
- Handles cases from initiation to end.
- Ensures members are satisfied with the service received by the provider.
- Assists members in locating providers in the area of choice.
- Assists the provider with all required pre-authorization.
- Performs other related tasks as assigned.
- Insurance Collection
Customer Service
HCA
01.2010 - 01.2012
- Insurance Verification/ Pre-Registration
- Perform pre-registration and insurance verification within 24 hours of receipt of reservation/notification for both inpatient and outpatient services
- Follow scripted benefits verification and pre-certification format in Meditech custom benefits screen and record benefits and pre-certification information therein
- Perform electronic eligibility confirmation when applicable and document results
- Research Patient Visit History to ensure compliance with payor specific payment window rules
- Complete Medicare Secondary Payor Questionnaire as applicable for retention in Abstracting module
- Calculate patient cost share and be prepared to collect via phone or make payment arrangement
- Utilize Meditech account notes and Collections System account notes as appropriate to cut and paste benefit and pre-authorization information and to document key information
Medical Insurance Billing and Coding Specialist
Cardiovascular Consultants of Florida
01.2004 - 01.2010
- Prepares and submits claims electronically to insurance companies.
- Hospital Billing and coding
- Accounts Receivables
- Identifies and resolves patient billing complaints
- Insurance Verification
- Setup budget payments plans for patients with delinquent accounts
- Check on claim status and correct claims as needed
- Appointment setting
- Medical Records
Medical Office Specialist (Reconstructive/ Cosmetic surgery)
Dr.Ramiro Morales
01.2003 - 01.2004
- Front desk Check in/ Check out
- Light medical assistant duties
- Appointment setting
- Data entry
- High volume customer service calls
- Scanning/Filing/Emailing
- Chart preparation
- Accounts Receivables/ Collections
- Minor surgery scheduling
Education
Medical Insurance Billing and Coding
Penn Foster School
06.2011
High School Diploma - undefined
American Academy High School
Miami, FL03.2004
Skills
- Over 10 years experience in healthcare field
- 6 years experience in hospital billing and coding
- Self motivated and confident in making independent decisions
- Fluent in both English and Spanish
- Excellent knowledge of Medical Terminology
- Demonstrated leadership in the absence of immediate supervisor
- Excellent in communication, interpersonal and organizational skills
- Proficient with Microsoft Word, Excel, Outlook and Internet
- Great organizational and communication skills
- Proficient with Medical Medware, Patient Keeper, Athena and Meditech
- Qualified to maintain confidentiality of patient and employee information
Timeline
Senior Customer Service Specialist
Provider Network Solutions
05.2024 - Current
Service, Team Lead
Account Technologies US
01.2022 - 01.2023
Customer Service Representative
Bupa/Blue Cross Blue Shield Global
01.2014 - 01.2020
Customer Service
HCA
01.2010 - 01.2012
Medical Insurance Billing and Coding Specialist
Cardiovascular Consultants of Florida
01.2004 - 01.2010
Medical Office Specialist (Reconstructive/ Cosmetic surgery)
Dr.Ramiro Morales
01.2003 - 01.2004
High School Diploma - undefined
American Academy High School
Medical Insurance Billing and Coding
Penn Foster School
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