Maggie Martinez
Albuquerque,NM
Summary
Goal-driven, compassionate, and accountable professional with 20+ years of experience in Managed Care with, along with strong auditing, compliance, training, and people management skills. Experience in claims, healthcare information . Creative thinker who is capable in cross-functional project management, methodologies, and techniques. Expert at gathering, analyzing, and defining business and functional requirements. Highly-motivated employee with desire to take on new challenges. Strong worth ethic, adaptability and exceptional interpersonal skills. Adept at working effectively unsupervised and quickly mastering new skills. Advanced user in Microsoft Office, Excel TRUCARE/ TRUCARE CLOUD, AMISYS, AND CENPAS.
Overview
15
15
years of professional experience
Work History
Authorization Research Specialist
Western Sky Community Care
Albuquerque, NM
10.2018 - Current
- Research claims inquiry specific to the department
- Work check run/pend reports and send claims to the claims department for corrections daily
- Verify claims through TRUCARE/ TRUCARE CLOUD, AMISYS, AND CENPAS
- Update auth providers, units and dates of service to update claims for payment
- Identify potential and documented eligibility issues and notify applicable departments to resolve
- Determine if claim is payable, if additional information is needed, or if claim should be denied
- Research and determine status of medical related claims
- Other duties include back up coordinating peer to peer meetings, creating authorizations, auto approving labor and delivery claims, generating approval/denial letters, monitoring phone queue.
Supervisor UM
Molina Healthcare
Albuquerque, NM
09.2013 - 09.2017
- Experienced in supervising a total of 11-12 team members
- Pulled and compiled reports, which included training on incoming authorizations as well as sending denial/approval letters
- Assisted team to build requests
- Assisted Manager of inpatient UM with monitoring and distribution of work to UR nurses
- Regularly worked on Lean Six Sigma projects
- Improved performance on various projects, including restructuring SharePoint site and improving processes
- Maintained proficiency in operating QNXT, UMK2, and A&G database
- Prepared security solutions for health care systems to prevent security weaknesses and system loopholes
- Automated manual and time-consuming processes to drive gains in data tracking, efficiency, and profitability
- Used leadership skills with the ability to lead implementations and deliver technical solutions – improving service delivery and productivity while providing IT solutions tied to business growth
- Defined manpower, resource requirements, and deadlines of IT projects according to defined project goals.
Case Specialist
Amerigroup
Albuquerque, NM
04.2009 - 09.2013
- Led managed care and services to members
- Worked in conjunction with Case Managers to coordinate health care services by facilitating, scheduling, and arranging a variety of treatment and care plans
- Cross-trained with Provider Relations – assisting with claim researching
- Utilized Citrix Macess application.
Education
Bachelors in Science Degree -
ITT Technical Institute
03.2010
Associates of Applied Science Degree -
ITT Technical Institute
12.2008
Skills
- Microsoft Office (Word, Excel, PowerPoint, Outlook, SharePoint)
- TRUCARE/ TRUCARE CLOUD
- AMISYS
- CENPAS
- MS Excel
- Data Entry
- Feedback Analysis
- Analytical Thinking
- Report Preparation
- Attention to Detail
- Analytical Skills
- Reliability
- Interpersonal Communication
- Problem-Solving
Timeline
Authorization Research Specialist
Western Sky Community Care
10.2018 - Current
Supervisor UM
Molina Healthcare
09.2013 - 09.2017
Case Specialist
Amerigroup
04.2009 - 09.2013
Bachelors in Science Degree -
ITT Technical Institute
Associates of Applied Science Degree -
ITT Technical Institute
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