Maria Cardines
Palmdale,CA
Summary
Self-motivated individual proudly offering over 6 years of experience building an understanding of medical terminology, claims and audit processing. A poised professional with benefits explanation and administration expertise. Offering time management and interpersonal skills.
Overview
9
9
years of professional experience
Work History
Appeals and Grievances Coordinator
Health Net, Centene
Remote
07.2022 - Current
- Process and finalize appeals and grievances within agreed-upon turnaround time.
- Provide outreach for additional information for appeals and grievances.
- Submitting verbal and written notification to members and providers.
- Manage large volume of documents including, faxing and scanning incoming mail
- Providing excellent service and attention to member’s through phone conversations.
- Maintaining files on individual appeals and grievance
- Resolves member’s complaints promptly and efficiently.
- Answers incoming calls from member’s and providers to assist with any questions or concerns.
- Analyzed complex cases to determine appropriate resolution in accordance with relevant laws, regulations and organizational policies.
- Prepared written responses to members regarding the status of their appeal or grievance filings.
- Collaborated with other departments within the organization to identify potential solutions for resolving the member’s disputes.
ER Pro Rep- Maximus/EDD
Manpower
Remote, CA
03.2022 - 06.2022
- Assessing information against requirements based on UI Code, Policies, and Procedures
- Sending employers standard forms to obtain additional information or resolve any discrepancy
- Working closely with subject matter experts to gain further understanding on how to address outstanding issues or identify when claims need to be escalated
- Reviewing and resolving complex issues referred by other front-line staff
- Reviewing wage and income information, benefits payments, and cross-matching to determine if payments were made appropriately
- Notating all actions taken on claims clearly and thoroughly
- Managing workload to meet deadlines
Team Lead
Centene Health Insurance
08.2019 - 07.2021
- Respond to escalated emails, and telephone inquiries for the membership accounting reps
- Prepares reports and documentation concerning department acclivities
- Works with staff and other departments to reconcile audit discrepancies and resolve eligibility questions
- Assist with special projects; maintain quality and production standards as outlined by the department.
- Monitors the unit's schedule for sufficient coverage
- Mentors and trains new associates
- Integrated process improvements to increase overall workflow.
- Organized and prioritized incoming work orders and optimized team workflows and resources to handle dynamic demands.
- Documented production levels, materials used and special incidents to keep management informed of daily activities.
- Developed and monitored weekly staff schedules.
- Followed staffing strategies to achieve production goals.
- Assisted management with interview process for on boarding eligibility reps.
- Participated in weekly meetings
Research Specialist
Centene Health Insurance
05.2019 - 08.2019
- Receive and respond to internal and external authorization related issues.
- Perform duties to ensure that authorization errors are corrected that could interfere with claims
- Assist with special projects; maintain quality and production standards as outlined by the department.
- Prepare training material
- Mentors and trains new associates
- Respond to escalated emails, and telephone inquiries for the membership accounting reps
- Prepares reports and documentation concerning department acclivities
- Works with staff and other departments to reconcile audit discrepancies and resolve eligibility questions
- Developed and maintained databases, pulling relevant data as needed.
Eligibility Rep I - Eligibility Rep III
Centene Insurance
02.2015 - 05.2019
- Provides project support, new hire training and coordination of open enrollment processing as needed.
- Researches information on subscribers to resolve problems and disputes.
- Maintains quality and production standards as outlined by the department.
- Assists with special projects.
- Ensured all reports were submitted and completed within compliance.
- Assisted with inbound and outbound calls
- Worked closely with team members to deliver project requirements, develop solutions and meet deadlines.
- Juggled multiple projects and tasks to ensure high quality and timely delivery.
- Provided excellent service and attention to customers through phone conversations.
- Improved operations by working with team members and customers to find workable solutions.
Education
High School Diploma
Skills
- Attention to detail; aptitude for problem
- Strong verbal and written communication
- Customer service personality eager to assist internal and external
- Team Management
- Recruiting
- Microsoft Office, Excel, Outlook & Lotus Notes email, Internet research
- Computer Skills
- Experience in leadership
- Conflict resolution
- Training
- Workplace safety
- Inventory Assessment
- Audit Preparation
- Time Management
- Organizing and Prioritizing Work
- Critical Thinking
Timeline
Appeals and Grievances Coordinator
Health Net, Centene
07.2022 - Current
ER Pro Rep- Maximus/EDD
Manpower
03.2022 - 06.2022
Team Lead
Centene Health Insurance
08.2019 - 07.2021
Research Specialist
Centene Health Insurance
05.2019 - 08.2019
Eligibility Rep I - Eligibility Rep III
Centene Insurance
02.2015 - 05.2019
High School Diploma