Manuel Garcia
Summary
5+ years of extensive knowledge of credentialing, Provider enrollment, medical terminology and accurately inputting and verifying large volumes of data. Detail-oriented Healthcare Professional with 4 years of experience in patient care and collaboration with other health care professionals and providers
Overview
8
8
years of professional experience
Work History
Sr. Specialist II, Training & Quality
Commonwealth Care Alliance
10.2023 - Current
- Provide training to Member Services, Provider Services, and off phone team upon hire as well as ongoing re-training throughout the year
- Create and maintain training materials including slide deck, exams, quizzes, role play scenarios, hands on activities, and worksheets
- Training topics include new hire onboarding, training to support role changes, system implementations, process updates, and annual refreshers
- Maintain and update documents to meet trainee needs as well as reflect updates to CCA policies
- Monitor Member Services and Provider Services verbal communications with members, providers, representatives, and other callers to ensure compliance with policies, procedures, and regulations as well as to ensure satisfactory customer service experience
- Complete required monitoring documentation, such as call monitoring scorecard, and autofailure emails, to capture successes and areas for improvement
- Provide feedback and coaching to trainees on their performance, strengths, and areas for improvement
- Lead process improvement projects and writing process improvement plan to help operations meet and exceed quality standards and streamline processes
- Participate in development of new programs, system implementations, and department initiatives
- Assist with protocols related to Member Services, Provider Services, and off-phone teams, providing support throughout the day, troubleshooting, and problem-solving issues raised by staff, leadership, vendors, and other departments
- Use computerized systems for tracking, information gathering and troubleshooting
- Assist with advanced data error corrections in database systems when needed
- Complete other duties as assigned.
Member Service Representative
Commonwealth Care Alliance
11.2021 - 10.2023
- Respond and effectively triage member phone calls to accurately and timely route to appropriate area
- This includes communication with clinical staff, processing of referrals, reimbursements, and disenrollment, and capturing complaints and service requests in a timely and comprehensive manner
- Work with healthcare management team to address the needs of members, caregivers and other CCA constituents
- Initiates Prior Authorization Intake process and attend to erroneous member billing discrepancies
- Complete comprehensive appeal and grievance intakes
- Meticulously document all member and prospective member interactions in a Centralized Electronic System
- Responsible for scheduling of member appointments, transportation, translation, and interpretation services
- Assist in the collection of supporting data and documentation relevant to member's care and connecting members to their CCA providers thru Telemedicine accessibility
- Assisted customers in navigating insurance claims, resulting in fewer denials and improved coverage understanding
- Maintained accurate records of drug inventory and orders for pharmacy customers
- Confirmed customer information and insurance eligibility for prescriptions.
Implementation Data Specialist/Unemployment Claims Specialist
FH Cann & Associates Inc (Contract)
10.2019 - 11.2021
- Helped Customers with past due Tuition and Federal school loan accounts get into good standing
- Reviews and audits the implementation data for accuracy and scan/upload Docs sent in with sensitive information
- Works closely with Client service Coordinators to identify inaccuracies in the data entered
- Assist in the development of internal reference and training materials
- Provided Team lead Second voice for other reps when needed
- Handle multiple accounts and send out paid invoices to clients and past due bills to customers at the end of the month
- Prepare and present audit reports for management to identify the issue and performance.
- Sent out letters regarding Determination status and documentation verification request
- Conducted Weekly meetings for those needing assistance with finding employment and enroll them in Job Fair seminars
- Maintained up-to-date knowledge of federal and state regulations governing unemployment insurance programs, always ensuring compliance
Provider Enrollment/Medical Data Entry Clerk
Conduent (Contract)
09.2017 - 09.2019
- Screens, tracks, reports, processes, inputs, and completes incoming Medicaid provider enrollment applications and revalidation into MMIS Portal.
- Work from home to meet daily criteria if needed
- Collect and manage patient eligibility documents such as prescriptions, certificates of medical necessity, letters, and prior authorization
- Contact doctor offices as necessary to collect provider clinical notes
- Assists all internal departments, providers, and potential providers with resolving Provider Enrollment issues and inquiries
- Meets quality controls and production standards of Provider Relations Department
- Trained and informed Medicaid clients on their benefits and representatives on how to administer them
- V Look Up.
Billing Specialist
Associated Home Care (Contract)
03.2016 - 08.2017
- Assist Billing Manager to maintain up-to-date billing system
- Be the primary person accountable for a selection of contracts
- Processed incoming orders, coordinated shipments, and handled customer-related issues
- Carry out billing, collection, payroll and reporting activities according to specific deadlines
- Communicate with customers via phone and email
- Assist with posting and reconciling timesheet discrepancies as needed
- Order supplies for offices as needed
- Supports team ensuring Standard Works are up to date with workflow process improvements.
Education
AS Business Management in Business -
NORTHERN ESSEX COMMUNITY COLLEGE
Lawrence, MAHigh School Diploma -
LAWRENCE HIGH SCHOOL
Lawrence, MA06.2015
Skills
- Call Auditor
- Efficient at typing
- Payroll experience
- Great customer service skills
- Proficient with computers
- Documentation Management
- Credentialing
- Onboarding
- Data Entry
- Filing
- Cash Handling
- Proven leadership skills
- HIPAA Compliance
- Medicare/Medicaid Knowledgeable
- Financial reports
- Remote Learning
- New Hire Training
Systems
- Proficiency in Microsoft software (Word, Excel, PowerPoint and Outlook)
- SalesForce (CRM)
- QuickBooks
- CACTUS
- Navitus NCRx (Prescription Lookup)
- Market Prominence
- ADP
- Payspan
Languages
English
Spanish
Timeline
Sr. Specialist II, Training & Quality
Commonwealth Care Alliance
10.2023 - Current
Member Service Representative
Commonwealth Care Alliance
11.2021 - 10.2023
Implementation Data Specialist/Unemployment Claims Specialist
FH Cann & Associates Inc (Contract)
10.2019 - 11.2021
Provider Enrollment/Medical Data Entry Clerk
Conduent (Contract)
09.2017 - 09.2019
Billing Specialist
Associated Home Care (Contract)
03.2016 - 08.2017
AS Business Management in Business -
NORTHERN ESSEX COMMUNITY COLLEGE
High School Diploma -
LAWRENCE HIGH SCHOOL