Marleny Pineda
Sylmar,CA
Summary
Skilled in policy knowledge and teamwork, I excelled at Health Net by streamlining grievance processes and enhancing member satisfaction. My assertiveness and problem-solving abilities contributed to surpassing performance metrics, demonstrating professionalism and effective dispute resolution. My approach consistently improved operational efficiency and customer service standards.
Overview
5
5
years of professional experience
Work History
Appeals and Grievances Coordinator
Health Net
West Hills, CA
04.2022 - 12.2023
- Processed and finalized appeals and grievances within agreed-upon turnaround time.
- Prepared response letters for members and providers with resolution to cases by mail.
- Remained knowledgeable regarding company policies and procedures and current developments within operational departments.
- Submitted verbal and written notification to members and providers.
- Contributed to organizational goals by consistently meeting or exceeding established performance metrics related to appeals and grievances management.
- Maintained strict confidentiality of sensitive member information while adhering to HIPAA regulations during case investigations.
- Demonstrated high-level attention to detail when reviewing medical records, provider contracts, and other relevant documents during case assessments.
- Expedited resolution times by proactively communicating with members, providers, and other stakeholders throughout the grievance process.
- Improved member satisfaction by efficiently managing and resolving appeals and grievances cases.
- Provided exceptional customer service when interacting with individuals involved in each appeal or grievance situation, demonstrating empathy and professionalism at all times.
Front Desk Receptionist
Providence St Jude Hospital
Burbank, CA
01.2022 - 03.2022
- Checked patient insurance, demographic, and health history to keep information current.
- Helped patients complete necessary medical forms and documentation.
- Coordinated patient scheduling, check-in, check-out and payments for billing.
- Ensured HIPAA compliance by maintaining strict confidentiality with all patient records and information.
- Remained aware of provider schedules and scope of practice on evolving basis to organize and schedule appropriate care.
- Managed a high volume of incoming calls, addressing inquiries, and providing exceptional customer service to patients.
- Handled financial transactions related to copayments or self-pay fees while adhering to company policies regarding payment collection.
- Coordinated appointment reminders for patients via phone calls or email notifications, reducing no-show rates.
- Kept waiting room neat and organized by stacking magazines, removing trash, and cleaning glass.
- Increased accuracy in data entry tasks by regularly updating patient demographics and insurance information.
- Enhanced patient satisfaction by consistently providing friendly and efficient service at the front desk.
- Provided administrative support to medical staff, assisting with various clerical tasks as needed.
Medical Biller/Claims Team Leader
The Holman Group
West Hills, CA
10.2019 - 12.2021
- Processed high volumes of medical claims accurately and efficiently under tight deadlines, ensuring prompt payment for services rendered.
- Researched and resolved complex medical claims issues to support timely processing.
- Maintained knowledge of benefits claim processing, claims principles, medical terminology, and procedures and HIPAA regulations.
- Verified patient insurance coverage and benefits for medical claims.
- Managed large volume of medical claims on daily basis.
- Monitored and updated claims status in claims processing system.
- Paid or denied medical claims based upon established claims processing criteria.
- Assessed medical claims for compliance with regulations and corrected discrepancies.
- Maintained a thorough understanding of the intricacies involved in processing medical claims for diverse healthcare specialties, enabling accurate and efficient claim adjudication.
- Streamlined communication between departments by developing efficient methods for sharing claim status updates and relevant documentation.
- Contributed to positive team morale through active participation in department meetings, offering constructive feedback, and supporting colleagues when needed.
- Assisted in the development of training materials for new hires, improving overall team knowledge and productivity.
- Provided exceptional support during audits by supplying detailed records of claim transactions as needed, ensuring full transparency into department operations.
Medical Biller/Front Desk Receptionist
Pain Management
Tarzana, CA
06.2019 - 10.2019
- Verified insurance of patients to determine eligibility.
- Communicated with insurance providers to resolve denied claims and resubmitted.
- Filed and updated patient information and medical records.
- Ensured timely payments from insurance providers through submission of accurate and complete claims.
- Maintained compliance with industry regulations by staying updated on changes to medical billing codes and requirements.
- Organized filing system for patient records, expediting access to essential documents when needed.
- Assisted patients in understanding insurance benefits, leading to a positive experience during their visit.
- Answered telephone calls to offer office information, answer questions, and direct calls to staff.
- Enhanced patient satisfaction by efficiently scheduling appointments and managing cancellations.
- Assisted in reducing no-shows by implementing reminder calls and appointment confirmation protocols.
- Assisted in maintaining a clean, organized work environment that fostered efficient daily operations within the clinic setting.
- Maintained confidentiality of patient information to comply with HIPAA regulations and protect patient privacy.
Education
MBIC Program - Medical Billing And Coding Certificate
UEI College
Encino, CA06.2019
High School Diploma -
Sylmar Charter High School
Sylmar, CA06.2007
Skills
- Policy Knowledge
- Dispute Resolution
- Assertiveness
- Teamwork and Collaboration
- Problem-solving abilities
- Multitasking Abilities
- Professionalism
- Written Communication
Languages
Spanish
Native or Bilingual
Timeline
Appeals and Grievances Coordinator
Health Net
04.2022 - 12.2023
Front Desk Receptionist
Providence St Jude Hospital
01.2022 - 03.2022
Medical Biller/Claims Team Leader
The Holman Group
10.2019 - 12.2021
Medical Biller/Front Desk Receptionist
Pain Management
06.2019 - 10.2019
MBIC Program - Medical Billing And Coding Certificate
UEI College
High School Diploma -
Sylmar Charter High School