Marlon J. Garcia
Bronx,NY
Summary
- Experienced healthcare professional with 10+ years of experience in working with HMO’s and healthcare management.
- Bilingual, results-focused leader specializing in driving practice growth, building solid teams, creating strategic initiatives, providing world-class service, and cultivating a strong company image with superior quality eager to offer progressive experience toward maximizing an employer’s bottom-line results.
- Top performer who makes decisions to reflect positively on facility well-being and staff satisfaction, and supports quality recruitment to encourage diversity, low turnover, and team loyalty in alignment with the company’s vision, value, and goals.
Overview
10
10
years of professional experience
Work History
Managed Care Specialist
New Jewish Home-Life Care
11.2021 - Current
- Skilled Nursing and Rehabilitation Center
- Point Click Care (PCC) Experience
- Verification of Benefit / Census Information Input Prepare and submit billing to Insurance Companies or other payers.
- Billing Manage Care A/B , Medicare A/B, Medicaid, Hospice, and Co-Insurance Secondary
- AR Reports, Denials, Overpayment and Appeal Review.
- Process ACH, Paper Payments, Payment posting
- Follow up on Delinquent Claim and Past Due Invoices.
- Always Adhere to strict HIPPA Guidelines to Protect Patient Privacy. Managed time efficiently in order to complete all tasks within deadlines.
Appeals and Grievances Coordinator
Metropolitan Jewish Health Care Systems (MJHS)
01.2019 - 10.2021
- Investigate and respond to over forty (40) written and verbal appeals and grievances weekly submitted by members and providers in accordance with Elderplan Contract Benefits, CMS, and DOH regulations.
- Assist clinical staff in presenting cases to Medical Directors by investigating, obtaining clinical data using HR Payor, Emdeon and Altruista, and analyzing final components.
- Meticulously track all correspondences and documents sent to and from LIVANTA, Maximus Federal, Fair Hearings, and External Appeal, as well as process and track administrative determination and claim appeals using Excel.
- Prepare case narratives, including the chronology of events for all completed files, as well as create over ten (10) Acknowledgement and Determination letters weekly.
- Ensure delivery of optimal customer services by working cross functionally with internal business units and external stakeholders, including physicians, attorneys, and the appropriate government agencies
Appeals and Grievances Specialist
Centerlight Healthcare Systems
01.2016 - 12.2018
- Captured and resolved all complaints regarding bills, dissatisfaction with services, and access to care issues related to Medicaid, Medicare, and all new lines of business.
- Ensured all adverse determinations were reviewed for medical necessity and ensured final disposition of member’s appeal or complaint was compliant with NCQA, DOI, DOL, MAXIMUS, State or Federal regulations.
- Communicated directly with payor to resubmit denied claims, underpaid claims and claims that were inaccurately processed by auditing accounts to check on proper payments, balances, adjustments, and using appropriate reports and work queues.
- Ensured appropriate resolution to inquiries, grievances and appeals within specified timeframes as well as appropriateness of response in compliance with State and Federal guidelines.
- Prepared response letters, notifications, and acknowledgements for members and provider complaints, grievances, and appeals.
Intake and Operational Services Supervisor
Care To Care LLC.
03.2014 - 01.2016
- Applied strong leadership talents and problem-solving skills to maintain team efficiency and organize workflows.
- Handled customer complaints, resolved issues, and adjusted policies to meet changing needs.
- Maintained clean and well-organized production areas to avoid violations or unnecessary work delays due to hazards or inefficient layouts.
- Monitored workflow to improve employee time management and increase productivity.
- Achieved results by working with staff to meet established targets.
- Mentored newly hired employees on operating equipment and safety and developed training manual to use for reference.
Education
Bachelor of Science - Small Business Administration And Management
DeVry University
Villa Park, IL02.2022
Skills
- Critical Thinking
- Provider Relations
- Financial Analysis
- Organizational Skills
- Team Leadership
- Case Management
- Adaptability
- Quality Improvement
Timeline
Managed Care Specialist
New Jewish Home-Life Care
11.2021 - Current
Appeals and Grievances Coordinator
Metropolitan Jewish Health Care Systems (MJHS)
01.2019 - 10.2021
Appeals and Grievances Specialist
Centerlight Healthcare Systems
01.2016 - 12.2018
Intake and Operational Services Supervisor
Care To Care LLC.
03.2014 - 01.2016
Bachelor of Science - Small Business Administration And Management
DeVry University
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