Maribel Cantu Espinoza
McAllen,TX
Summary
Highly-motivated employee with a passion for taking on new challenges and driving results. Possesses a strong work ethic, adaptability, and exceptional interpersonal skills. Adept at working effectively both independently and as part of a team, with a proven ability to quickly master new skills and tasks. Committed to delivering excellence in all endeavors and contributing positively to organizational goals and objectives.
Overview
16
16
years of professional experience
1
1
Certification
Work History
Investigator
Texas Health and Human Services Commission, Office of Inspector General
Edinburg , TX
2021.11 - Current
- As an experienced professional in Medicaid provider fraud investigations, I excel in conducting thorough investigations into alleged program violations, employing a comprehensive range of techniques including data evaluation, evidence collection, and witness interviews
- With a meticulous approach to analyzing large datasets and designing samples, I contribute significantly to the identification of fraudulent activities
- I am adept at summarizing investigative findings according to established policies and procedures, ensuring clarity and accuracy in case documentation
- My strong communication skills enable me to effectively convey findings to key stakeholders both within the Health and Human Services Commission (HHSC) and external agencies, including through testimony in legal proceedings
- I actively foster collaborative relationships with relevant entities such as the Attorney General's Medicaid Fraud Control Unit and state/federal agencies, facilitating joint investigations and providing expertise to enhance program integrity
- Additionally, I am proactive in recommending policy enhancements to combat fraud, waste, and abuse effectively
- With a commitment to excellence and adaptability to diverse tasks, I am prepared to undertake any additional duties required to support division operations.
Program Specialist VI
Texas Health and Human Services Commission, Manage Care Compliance Organization
Austin , TX
2020.10 - 2021.11
- Served as a pivotal point for handling and routing medical necessity information to support members with complex medical needs, particularly those within the Deaf/Blind Multiple Disabilities (DBMD) and Medically Dependent Children’s Program (MDCP) Helpline
- This entails receiving requests for external medical reviews, compiling essential data for initial necessity determinations, and ensuring prompt assignment and completion of reviews by enrolled independent organizations
- I meticulously monitored performance measures, providing valuable insights into contractor compliance with contractual obligations
- Collaborating seamlessly across departments, I contributed to the development of innovative solutions for both clients and staff, particularly in resolving highly intricate concerns involving Medicaid members, managed care organizations (MCOs), and internal HHSC staff
- Coordinated the collection, organization, and analysis of materials for external review requests, ensuring adherence to program policies and procedures while maintaining the timely processing of requests
- Offered critical support as a backup for the MDCP and DBMD helpline, assisting members in accessing necessary services and supports, even during flexible hours, holidays, and weekends
- As a proactive team lead and supervisor backup, I efficiently allocated tasks and ensured seamless operations in the supervisor's absence
- Contributed to policy development, delivered comprehensive trainings for providers and stakeholders, and applied my leadership, project management, and time management skills to drive successful project execution.
Program Specialist III
Texas Health and Human Services Commission, Manage Care Compliance Organization
Pharr , TX
2018.08 - 2020.09
- Specialized in addressing complex inquiries and complaints related to Managed Care Organizations (MCOs)
- Composed written responses to clients, agency staff, providers, stakeholders, advocates, and legislators, drawing upon my comprehensive knowledge of local, state, and federal laws, rules, and regulations
- With a keen understanding of Texas Medicaid/CHIP guidelines, I interpreted and applied policies to resolve client and provider/stakeholder issues efficiently
- My responsibilities included receiving, analyzing, processing, and responding to inquiries and complaints pertaining to MCOs, ensuring timely entry into the HEARTS tracking system and effective communication with MCOs and HHSC staff until resolution
- I consistently monitored MCO performance against contract standards and quality improvement goals, providing valuable insights for performance enhancement
- Additionally, I collaborated closely with the Health Plan Management team to address compliance and quality improvement issues, contributing to the development and monitoring of corrective action plans
- Actively participated in special projects and investigations, demonstrating my ability to analyze data, coordinate with stakeholders, and ensure compliance with contractual obligations
- My commitment to excellence and effective communication skills enabled me to establish and maintain productive working relationships with diverse stakeholders, contributing to the overall success of the team.
Texas Works Advisor
Texas Health and Human Services Commission
Alamo , TX
2014.06 - 2018.08
- Assisted in interpreting policy, completing unit reports, resolving, and responding to client complaints
- Reviewed case records to determine compliance with policies and procedures to identify trends and for corrective action
- Required knowledge of local, state and federal laws, rules, and regulations for all state programs
- Assisted in developing standards or procedures for assigned area
- Interviewed clients or authorized representatives to gather information to determine eligibility for SNAP, Medicaid, TANF, and MEPD programs
- Obtained, verified, and calculated income and resources to determine client financial eligibility and validate eligibility decisions
- Developed payment plans to facilities to ensure accuracy of payments
- Documented case records using automated equipment to form a record for each client
- Explained program benefits or requirements to clients
- Communicated on an intermediate level with others (internally or externally) to provide, exchange, or verify information, answer inquiries, address issues, or resolve problems or complaints
- Managed assigned projects
- Worked in a highly stressful and fast-paced environment, under constant pressure to meet required deadlines
- Assisted supervisor with case readings to assure accuracy from other employees
- Assisted supervisor with any extra projects assigned
- Assisted with mentoring new employees.
Eligibility Specialist
Texas Health and Human Services Commission
Hartford , MI
2008.04 - 2012.07
- Assisted in interpreting policy, completing unit reports, resolving, and responding to client complaints
- demonstrated ability to handle a full caseload of migrant and Spanish-speaking clients
- Reviewed case records to determine compliance with policies and procedures to identify trends and for corrective action
- Required knowledge of local, state and federal laws, rules, and regulations for all state programs
- Assisted in developing standards or procedures for assigned area
- Interviewed clients or authorized representatives to gather information to determine eligibility for SNAP, Medicaid, TANF, and MEPD programs
- Obtained, verified, and calculated income and resources to determine client financial eligibility and validate eligibility decisions
- Developed payment plans to facilities to ensure accuracy of payments
- Documented case records using automated equipment to form a record for each client
- Explained program benefits or requirements to clients
- Communicated on an intermediate level with others (internally or externally) to provide, exchange, or verify information, answer inquiries, address issues, or resolve problems or complaints
- Managed assigned projects
- Worked in a highly stressful and fast-paced environment, under constant pressure to meet required deadlines
- Assisted supervisor with case readings to assure accuracy from other employees
- Assisted supervisor with any extra projects assigned
- Assisted with mentoring new employees.
Education
H.S diploma -
Hartford High School
Bachelor of Science in Criminal Justice Administration -
University of Phoenix
Master of Public Affairs -
University of Texas Rio Grande Valley
Skills
- Conducting in-depth analysis of complex inquiries and complaints
- Composing written responses to clients, agency staff, stakeholders, advocates, and legislators
- Knowledge of local, state, and federal laws, rules, and regulations
- Performing basic and challenging arithmetic functions
- Maintaining working relationships with staff at all levels
- Oral and written communication for diverse audiences
- Operating computer equipment, Xerox, printers, and ten-key calculator
- Establishing and maintaining effective working relationships, negotiating, and conflict resolution
- Organizing, prioritizing, writing, proofreading, editing, filing, record-keeping, and interpersonal communication
- Leadership, project management, time management, and organizational skills
- Proficient in using various computer applications, including Microsoft Office suite, internet tools, and specialized eligibility systems
- investigation skills
- Insurance fraud
- Records handling
- Interview techniques
- Risk Analysis
- Risk Assessment
- Research abilities
- Data review
- Research skills
- Evidence collection
- Report Development
- Claims resolution
- Deadline and results-oriented
- Continuous Improvement
- Excellent customer service skills
Certification
- Certified Texas Contract Manager, License number 1900016592
References
References available upon request.
Timeline
Investigator
Texas Health and Human Services Commission, Office of Inspector General
2021.11 - Current
Program Specialist VI
Texas Health and Human Services Commission, Manage Care Compliance Organization
2020.10 - 2021.11
Program Specialist III
Texas Health and Human Services Commission, Manage Care Compliance Organization
2018.08 - 2020.09
Texas Works Advisor
Texas Health and Human Services Commission
2014.06 - 2018.08
Eligibility Specialist
Texas Health and Human Services Commission
2008.04 - 2012.07
H.S diploma -
Hartford High School
Bachelor of Science in Criminal Justice Administration -
University of Phoenix
Master of Public Affairs -
University of Texas Rio Grande Valley
- Certified Texas Contract Manager, License number 1900016592
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