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
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
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
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
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