Jose L. Estela
St. Johns,FL
Summary
Results-driven healthcare professional with extensive medical claims experience and clinical pharmacy expertise in comprehensive clinical review.
Overview
13
13
years of professional experience
Work History
Humana Clinical Pharmacy Review Representative
Humana Inc
Remote Nationwide
10.2025 - Current
- Processed prior authorization requests for specialty medications according to established protocols.
- Reviewed prior authorization submissions for completeness and accuracy prior to submission.
- Submitted prior authorization requests electronically or by phone to payers.
- Researched payer requirements for prior authorization requests from providers.
- Answered inquiries from providers, members, pharmacies. regarding status of prior authorization requests.
- Coordinated with other departments to obtain additional information needed for prior authorization.
- Collaborated with other departments to ensure accurate completion of prior authorization requests.
- Monitored reports detailing utilization of medications requiring prior authorization approval.
- Educated healthcare providers on prior authorization requirements and insurance formulary changes.
Medical Claims Specialist
Blue Cross and Blue Shield
Remote Nationwide
11.2023 - 10.2025
- Processed medical claims using advanced billing software and systems.
- Analyzed claims data to identify trends and potential issues in submissions.
- Reviewed and resolved denials, rejections, and underpayments from insurance carriers to ensure accurate claim processing.
- Resolved issues related to denied or underpaid claims in a timely manner.
- Processed and filed appeals on rejected or partially paid claims, ensuring timely resolution and compliance with guidelines.
- Provided feedback on coding errors and discrepancies found in submitted claims.
- Sent clinical request and missing information letters to obtain incomplete information.
- Applied group-specific classifications to claims using contract notes and processing manual to maintain accuracy in submissions.
- Processed claims for payment or forwarded to appropriate personnel for further investigation
Front Desk Agent
Developer Inn & Suites
Jacksonville, FL
11.2022 - 10.2023
- Welcomed patrons to front desk and engaged in friendly conversations while conducting check-in process.
- Answered telephones and greeted visitors to assist with inquiries and direct to appropriate staff.
- Greeted incoming guests warmly, issued room keys and shared information on policies and amenities.
- Worked with housekeeping and maintenance staff to address and resolve building and room issues.
- Posted charges, updated accounts, and issued accurate bills to ensure smooth check-out process.
- Received incoming calls and coordinated with staff to fulfill customer requests.
- Input customer data into reservation systems and updated to reflect room changes.
- Responded to inquiries and room requests made online, by phone and via email.
- Enhanced guest satisfaction by addressing inquiries about operations and policies, resolving concerns effectively, and creating tailored solutions.
- Stayed current on local attractions and special events to help guests with entertainment options.
Front Desk Agent
Hudson Hotel
New York, NY
06.2013 - 10.2022
- Greeted guest upon arrival and assist them with check -in process. Verified guest information, such as identification and payment details. Provided room keys and necessary information about hotel services, facilities and policies. Processed payments, including cash, credit cards and other method. Handled guest check-outs efficiently, ensuring accuracy in billing and resolving any discrepancies.
- Responded promptly to the guest inquiries, concerns and requests in a friendly and professional manner. Provided information about hotel amenities, local attractions, and directions. Arranged transportation, restaurant, reservations and other services as requested by guest. Handled guest complaints or issues diplomatically, finding appropriate solutions to ensure guest satisfaction.
- Assisted guests with making or modifying room reservations over the phone, in person or online. Maintained accurate and up to date records of guest bookings and reservations. Coordinated with other hotel departments, such as house keepping and maintenance, to ensure room availability and readiness.
- Performed general administrative duties such answering phone calls, responded to emails, managed guest messages. Maintained and update gust information in the hotel management system. Prepared and distributed daily reports, including occupancy, arrivals, departures and special request. Handled financial transactions, including cash handling, maintained a balance cash drawer.
- Ensured the safety and security of the guest by following hotel policies and procedures. Monitored the lobby area and report and suspicious activities or security concerns to the appropriate personnel. Handled emergency situations calmly and efficiently such as fire alarms or medical emergencies, by following established protocols.
Skills
- Health benefits navigation
- Customer service
- Problem-solving skills
- Bilingual English and Spanish
- Prior authorization processing
- Customer relationship management
- Document accuracy review
- Claim coding accuracy
- Analytical and critical thinking
- Attention to detail
- Claim processing
Timeline
Humana Clinical Pharmacy Review Representative
Humana Inc
10.2025 - Current
Medical Claims Specialist
Blue Cross and Blue Shield
11.2023 - 10.2025
Front Desk Agent
Developer Inn & Suites
11.2022 - 10.2023
Front Desk Agent
Hudson Hotel
06.2013 - 10.2022