MARTHA A. MENDOZA GAMEZ
Kissimmee,FL
Overview
11
11
years of professional experience
Work History
Care Coordinator
OPTUM Poinciana
Poinciana, FL
01.2014 - Current
- Responsible for functions in areas such as health services, clinical services and delivery of clinical care
- Job Function Description Positions in this function includes those responsible for initial triage of members, administrative intake of members or managing the admission/discharge information post-notification, working with hospitals and the clinical team
- Manage incoming calls, manage requests for services from providers/members, providing information on available network services and transferring members as appropriate to clinical staff
- Manage the referrals process, processes incoming and outgoing referrals, and prior authorizations
- Includes intake, notification and census roles
- Moderate work experience within own function
- Some work is completed without established procedures
- Basic tasks are completed without review by others
- Serve as primary point of contact for providers or members regarding medical/behavioral/clinical Job Profile: Clin Admin Coord-23 services or benefits -Extract and review fax requests for medical or clinical services Receive calls requesting medical/behavioral/clinical services or benefits information (e.g., from providers or members) Receive electronic referral form requests for medical/behavioral/clinical services -Utilize phone system to respond to and transfer calls to appropriate individuals Ask callers standard questions to understand requests, gather necessary information, and assess urgency Access electronic member files using policy or id number Determine member eligibility Follow protocols to task requests appropriately Check procedure codes against notification requirements and benefit coverage to determine next steps Access claims information Review and interpret call history documentation (e.g., case notes) Navigate between computer screens and platforms to research information (e.g., medical, clinical, or benefits information) Take calls and questions from members and/or providers regarding case status Determine whether authorizations are required for requested medical services Reference automated job aid tools via computer to research relevant rules, regulations, or procedures Learn computer system and process changes and updates and incorporate into daily work Contact internal resources if necessary to clarify information Identify appropriate resource (e.g., doctor, resource, contracted provider) to respond to medical requests Process Medical/Behavioral/Clinical Services or Benefits Requests Provide/explain benefit information to members/providers Provide/explain authorization information to members/providers Communicate with clinical team to ensure provider receives a response when necessary Document call history information into relevant computer system Enter medical request data into relevant computer system Follow standard procedures to complete requests Request medical review via relevant computer system as needed Review and advise member/provider of status of a request (e.g., notification, authorization) Schedule appointments for members based on request Provide information regarding appointments and medical services to facilities staff to assist members
Education
Associate of Arts -
Valencia
Poinciana, FL05.2018
Health Science -
Polk State College
Winter Haven, FL08.2005
Skills
- Apply knowledge/skills to activities that often vary from day to day
- Demonstrates a moderate level of knowledge and skills in own function
- Require little assistance with standard and non-standard requests
- Solve routine problems on own
- Work with supervisor to solve more complex problems
- Prioritize and organize own work to meet agreed upon deadlines
- Work with others as part of a team
- Knowledge with EMR systems; Athena and ECW
- Bilingual Spanish and English
- Utilize Microsoft Excel, Adobe, Microsoft Teams
- Medical terminology understanding
- Goal Setting
- Healthcare operations
- Case Management
- Insurance Practices
- Healthcare knowledge
- Policy Adherence
- Patient Education
- Scheduling
Languages
English
Professional
Spanish
Professional
References
References available upon request.
Timeline
Care Coordinator
OPTUM Poinciana
01.2014 - Current
Associate of Arts -
Valencia
Health Science -
Polk State College
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