Karla Nunez
Palmetto Bay,FL
Summary
Experienced healthcare operations professional with over ten years in provider and member services, focusing on claims support and eligibility verification. Skilled in enhancing service delivery and resolving complex inquiries through collaboration with clinical and administrative teams.
Overview
16
16
years of professional experience
1
1
Certification
Work History
Bilingual Patient Services Coordinator
Centauri-Jackson South Medical Center
Miami, Florida
10.2025 - Current
- Educated patients on services and answered questions to streamline application completion.
- Handled patient inquiries promptly, resolving issues in compliance with HIPAA regulations.
- Collaborated with team members and clients to identify and meet specific needs and expectations.
- Coordinated with physicians and hospital staff to gather necessary information for effective account follow-through.
- Conducted phone and in-person screenings to assess program eligibility and initiate client reimbursement.
- Reviewed daily referrals for interview appropriateness, gathering documentation and maintaining accurate notes.
- Supported post-discharge outreach by routing patients to appropriate agencies for additional assistance.
- Maintained data integrity while managing productivity and participating in team meetings.
Senior Customer Service Specialist
Provider Network Solutions
Doral, USA
02.2023 - 10.2025
- Resolved customer complaints promptly and efficiently.
- Facilitated communication between customers and departments, ensuring timely resolution of inquiries.
- Interpret paid and denied claims; explain denial reasons and next steps clearly and professionally.
- Educated providers on appeals and claim submission requirements, enhancing understanding of portal use.
- Verify member eligibility and benefits for providers; research accounts in TPA and health plan portals.
- Document all interactions accurately per policy; create internal tickets/PDRs and route issues for resolution.
- Analyzed customer feedback to identify trends, recommending process improvements for enhanced service.
- Implemented process enhancements to streamline customer service workflows effectively.
Senior Member Service Representative
Aetna Better Health of Florida
Doral, USA
01.2017 - 10.2022
- Resolved member, provider, and broker inquiries via phone, email, and written correspondence.
- Explained eligibility, benefits, and claim status; interpreted coverage and denial reasons using plan tools and guidelines.
- Processed and routed claim referrals, nurse review handoffs, and member/provider complaints, ensuring accurate documentation in required systems.
- Initiated outreach/welcome calls to support engagement, address barriers, and ensure service expectations were met.
- Identified complaint trends and collaborated with cross-functional partners to implement solutions, enhancing overall service delivery.
- Supported grievances and appeals workflows by escalating issues through appropriate systems, maintaining compliance with required timelines.
- Doral, FL
Grievance and Appeals Specialist
Humana CarePlus Health Plans
Doral, USA
11.2015 - 12.2016
- Managed member and partner complaints, grievances, and appeals, coordinating with internal teams and regulators to ensure timely resolution.
- Ensured compliance with regulatory and accreditation requirements by consistently meeting processing timelines and documentation standards.
- Analyzed trend data to identify recurring issues, recommending process improvements that enhanced member experience.
- Doral, FL
Care Review Processor
Molina Healthcare of Florida
Doral, USA
05.2013 - 09.2015
- Entered and tracked authorization requests and provider inquiries received via phone, mail, and fax to ensure timely processing.
- Reviewed diagnosis and treatment requests; validated coordination of benefits (COB) status.
- Reviewed ICD-9 and CPT codes and abstracted clinical data from medical records to support eligibility and authorization review.
- Researched and documented required procedure codes, including imaging (MRI/CT), and entered comprehensive notes into the database to support accurate authorization reviews.
- Requested and obtained missing information from provider offices, adhering to departmental guidelines to facilitate Medical Director review.
- Met productivity standards of up to 40 cases per day while maintaining accuracy and confidentiality; complied with HIPAA requirements.
- Doral, FL
Provider Services Representative
Molina Healthcare of Florida
Doral, USA
08.2010 - 05.2013
- Resolved inquiries from high-volume providers on claims, eligibility, and billing, ensuring timely support and issue resolution.
- Educated providers on regulatory updates, procedures, and access to plan information and tools.
- Provided claims and billing guidance for long-term care managed care programs (e.g., Assisted Living, Adult Day Care, Home Health, Skilled Nursing).
- Delivered training and support to providers, including web portal guidance during onboarding and onsite visits.
- Managed credentialing documentation and contributed to initiatives aimed at enhancing provider satisfaction.
- Doral, FL
Education
Medical - Technical School
ATI Training Career Center
Doral, FL01-2008
GED -
American Academy High School
Miami, FL01-2003
Skills
- Benefits verification
- Insurance verification
- Claims status
- QNXT
- QuickCap
- Denials
- Appeals support
- Appeals processing
- Grievance processing
- Provider customer service
- Member customer service
- Patient screening
- Healthcare documentation
- Documentation
- Case notes
- Data accuracy
- Cerner
- PowerChart
- PMOffice
- EDM
- Bilingual communication
- Insurance verification
Certification
Available upon request.
Languages
- English
- Spanish, Full Professional
- English, Full Professional
Timeline
Bilingual Patient Services Coordinator
Centauri-Jackson South Medical Center
10.2025 - Current
Senior Customer Service Specialist
Provider Network Solutions
02.2023 - 10.2025
Senior Member Service Representative
Aetna Better Health of Florida
01.2017 - 10.2022
Grievance and Appeals Specialist
Humana CarePlus Health Plans
11.2015 - 12.2016
Care Review Processor
Molina Healthcare of Florida
05.2013 - 09.2015
Provider Services Representative
Molina Healthcare of Florida
08.2010 - 05.2013
Medical - Technical School
ATI Training Career Center
GED -
American Academy High School