LEAH M. RIVERA
Redwood City,CA
Overview
18
18
years of professional experience
Work History
Member Services Representative
Alameda Alliance for Health
Alameda, CA
09.2023 - Current
- Serve as the primary contact for members, for questions related to claims, benefits, authorizations, pharmacy, member eligibility and other questions related to Alameda Alliance and provide accurate, satisfactory answers to their inquiries or concerns.
- Respond to and resolve member service inquiries and issues by identifying the topic and type of assistance the caller needs such as benefits, eligibility, claims, behavioral health, and care coordination.
- Process disenrollment request from the plan.
- Answer incoming calls, emails, chats, and other requests for assistance in a timely manner in accordance with departmental performance targets and provide excellent customer service while doing so. Also assist walk-in member inquiries and complaints.
- Recognize and understand the difference between calls that require quick resolutions and calls which will require follow-up and handle each appropriately.
- De-escalate situations involving dissatisfied customers, offering patient assistance and support.
- Accurately and consistently document (electronic database) and resolve Exempt Grievances.
- Interface with Grievance and Appeals, Claims, Enrollment, IT, Network Management, Pharmacy, Authorizations, and other internal departments to provide Service Excellence to our members.
- Help guide and educate members about the fundamentals and benefits of managed health care topics, to include managing their health and well-being by selecting the best benefit plan service options, maximizing the value of their health plan benefits, and choosing a quality care provider.
- Intercede with care providers (doctor’s offices) on behalf of the member, assisting with appointment scheduling; connect members with internal Case Management Department for assistance as needed.
- Assist members in navigating alamedaalliance.org, the Member Portal, and other health care partner online resources and websites to encourage/reassure them to use self-service tools that are available.
- Manage any issues through to resolution on behalf of the member, either on a single call or through comprehensive and timely follow-up.
- Research complex issues across multiple databases and work with support resources to resolve member issues and/or partner with others to resolve escalated issues.
- Provide education and status on previously submitted pre-authorizations or pre-determination requests for both medical and pharmaceutical benefits.
- Meet the performance goals established for the position in the areas of compliance, efficiency, call quality, member satisfaction, first call resolution, punctuality, and attendance.
- Always maintain a professional level of service to members.
- Always maintain confidentiality of information.
- Consistently support the Alliance’s approach to Service Excellence by adhering to established department and company standards for all work-related functions.
- Interact positively with all Alliance Departments.
- Process MS Dept projects.
- Perform other duties as assigned.
- Contacts: Receive, manage, and document telephone calls, Describe the types of services the Alliance offers to the Member within the managed care system.
- Resolve member problems/conflicts by convening with other departmental staff as needed.
- Create and/or mail appropriate member materials and communications as needed.
- Perform ongoing data entry which assists in the maintenance of the Member Services department database to ensure data integrity.
Patient Service Representative
Sutter Health (Dermatology)
Palo Alto, CA
04.2020 - 08.2023
- Serves as the first point of contact for patients entering the medical facility.
- Greets and checks-in patients, verifies information, schedules appointments, and updates Electronic Health record (EHR).
- Facilitates intake procedures such as completion of healthcare and insurance forms and collecting payments for services.
- Gains confidence and cooperation from the patient, their family/support group, and other healthcare providers through competent job performance and effective communication.
- Adheres to all organizational, local/state/federal regulations, codes, policies and procedures to ensure privacy and safety while delivering optimal patient care.
- Also processes Referrals from other Departments and outside facilities.
- Knowledge of computer applications, such as Microsoft Office Suite (Word, Excel and Outlook).
- Prioritize assignments and work within standardized policies and procedures to achieve objectives and meet deadlines.
- Work independently, as well as be part of the team, including accomplishing multiple tasks in an environment with interruptions.
- Identify, evaluate and resolve standard problems by selecting appropriate solutions from established options.
- Ensure the privacy of each patient’s Protected Health Information (PHI).
- Build collaborative relationships with peers and other staff members to achieve departmental and corporate objectives.
- Has EPIC experience for almost 10 years now.
Patient Registration Coordinator
CCRM-San Francisco (Colorado Center for Reproductive Medicine)
San Francisco
09.2018 - 04.2020
- Greet all patients and visitors as they enter the practice and check in each patient upon arrival.
- Responsible for gathering, updating and maintaining the patient demographic information.
- Responsible for scanning insurance cards, picture ID and prior medical records information into the patient’s medical record.
- Responsible for taking patient payments, procedure pre-payments, and past due balances and provide a receipt to the patient.
- Responsible for patient appointment scheduling and rescheduling patient appointments when needed.
- Communicate with patients in a timely manner when schedule changes are made.
- Assists medical record coordinator in processing medical records request from patient, insurance company and other facility.
- Answer phone calls, take and triage phone messages, forward calls based on urgency and in a timely manner.
- Responsible for assisting each patient with their appointments for the day, monitoring patient schedule to assure patient is getting to their appointment on time and with minimal wait time, effectively maintaining timely patient flow.
- Assist patient, staff, and provider, as needed and maintain positive relationships with other departments.
- Confirm that ordered test results are in the EMR prior to a patient’s appointment date with the provider.
- Responsible for calling each new patient who has not completed the new patient paperwork two days prior to their scheduled appointment.
- Check e-fax folders throughout the day and distribute all incoming faxes to appropriate staff member.
- Fax patient information, as directed.
- Assure the readiness of the lobby for each work day.
- Secure building at the close of each work day by locking all entrances, making sure that the waiting area and snack bar are clean.
- Train new employees, as requested.
Release of Information Specialist / Client Service Representative
STANFORD HEALTH CARE / CIOX (HIMS-RELEASE OF INFORMATION/MEDICAL RECORDS)
04.2015 - 09.2018
- Manages medical record requests from doctors (continuation of care), patient walk in requests attorneys/law firms/ insurance companies and Subpoena copy services.
- Follows HIPAA requirements and established procedures which govern release of information.
- Completes requests within established turnaround standards using EPIC systems.
- Interacts with patients and requesting parties both in person and via telephone.
- Works in a fast paced environment with high customer demands and stringent turnaround requirements.
- Majority of work involves use of electronic medical record and associated software applications.
- Last September 2015, I process Criminal/Juvenile, Civil, Workers Comp and Deposition subpoenas. I also process internal requests for Stanford Lawyers, Risk Management, Compliance Dept and Office of General Counsel including Audit requests.
Support Service Clerk / Custodian of Hospital Billing Records
STANFORD HEALTH CARE (Patient Financial Services- CCMC) / USCB
02.2014 - 03.2015
- Processing work queue and correspondence and add notes on EPIC.
- Redirecting phone calls to the assigned Rep so they can resolve the issue and provide what is being requested in a timely manner and if I can provide the resolution, I will do it myself instead of transferring calls to the Representative.
- Create insurance coverage (registration) and verify eligibility, also update insurance billing order on the system.
- Distributing correspondence to the assigned Rep and different departments like Government, Special Billing Unit, Professional billing, Cash Posting(for denied claims and Explanation of Benefits and Remittance Advice).
- Handling mailroom duties (backup), and respond to some requests like ordering Toner for fax machines and printer.
- As of September 2014, I handled subpoenas and authorizations to produce hospital billing records requested by Law firms/Attorneys and Legal Copy Services, making sure that the request is in HIPAA Compliance and that no sensitive diagnosis or patient information will be released without patient authorization or if there’s an objection letter received.
- Carefully review all the checks received (processing fee payment from the requester).
- Assisting refund team in processing refund requests (correspondence and via fax).
Insurance Billing and Collections Intern
BRENTWOOD CHIROPRACTIC / DR. PATEL CHIROPRACTIC
10.2013 - 12.2013
- Handled claims with different Insurances (HMO, PPO , Worker’s Compensation).
- Follow-up with insurance companies for the status of the claim.
- Corrected denial claims with right information and resubmit for reconsideration.
- Prepared / printed bills/claim form (CMS-1500) and faxed or mailed it to insurance companies.
- Follow up on unpaid claims as well as old claims.
- Daily input of patient charges after verifying that correct procedure codes were used.
Teller / Operations Specialist
UNIONBANK
01.2011 - 12.2013
- Assisted managers and staffs in developing and monitoring team performances and track results.
- Scheduled employees/ manager meetings and work schedule using Schedular 360.
- Completed daily reports in a timely manner in preparation for a quarterly audit.
- Guided other team members in following correct procedures when processing transactions and maintaining the confidentiality and security of customer accounts as well as the company.
Teller / Customer Service and Sales Representative
WELLS FARGO BANK
01.2008 - 12.2011
- Handled banking transactions which includes deposits, withdrawals, payments, as well as resolving customer complaints and issues.
- Set up new accounts and made sure that daily sales goals and quotas are met.
Timeline
Member Services Representative
Alameda Alliance for Health
09.2023 - Current
Patient Service Representative
Sutter Health (Dermatology)
04.2020 - 08.2023
Patient Registration Coordinator
CCRM-San Francisco (Colorado Center for Reproductive Medicine)
09.2018 - 04.2020
Release of Information Specialist / Client Service Representative
STANFORD HEALTH CARE / CIOX (HIMS-RELEASE OF INFORMATION/MEDICAL RECORDS)
04.2015 - 09.2018
Support Service Clerk / Custodian of Hospital Billing Records
STANFORD HEALTH CARE (Patient Financial Services- CCMC) / USCB
02.2014 - 03.2015
Insurance Billing and Collections Intern
BRENTWOOD CHIROPRACTIC / DR. PATEL CHIROPRACTIC
10.2013 - 12.2013
Teller / Operations Specialist
UNIONBANK
01.2011 - 12.2013
Teller / Customer Service and Sales Representative
WELLS FARGO BANK
01.2008 - 12.2011