Mary Melendez
Philadelphia,PA
Overview
24
24
years of professional experience
Work History
Referral Coordinator
Central Florida Kidney Specialist
Orlando, FL
01.2023 - 12.2023
- Processed referral requests from patients, doctors and other health care professionals.
- Responded to patient inquiries to offer timely updates regarding referral status.
- Called insurance companies to get precertification and other benefits information on behalf of patients.
- Monitored referrals to foster timely completion and followed up with physicians to facilitate.
- Developed and maintained strong working relationship with referral sources to streamline processing.
- Developed and updated policies and procedures, maintaining compliance with guidelines relating to HIPAA, benefits administration and general liability.
- Updated EHR with pertinent demographic and insurance information.
Insurance Verification Specialist
West Orlando Pediatrics
Ocoee, FL
10.2022 - 03.2023
- Front Desk check-in/ check-out
- Complied with HIPAA guidelines and regulations for confidential patient data.
- Assisted patients with understanding personalized insurance coverage and benefits.
- Assured timely verification of insurance benefits prior to patient procedures or appointments.
- Made contact with insurance carriers to discuss policies and individual patient benefits.
- Managed high-volume insurance verifications within pressured timeframes for productive medical operations.
- Updated patient records with accurate, current insurance policy information.
- Trained new staff on current, correct insurance verification procedures.
- Answered telephone calls to offer office information, answer questions, and direct calls to staff.
- Posted payments to accounts and maintained records.
- Generated reports to track insurance verifications and claim progress.
- Performed various administrative tasks by filing, copying and faxing documents.
- Assisted with medical coding and billing tasks.
- Scheduled appointments, registered patients, and distributed sample pharmaceuticals as prescribed.
- Verified patient insurance coverage and collected required co-payments.
- Oriented and trained new staff on proper procedures and policies.
Case Specialist
QTC MANAGEMENT
01.2015 - 12.2020
- Responded to telephone requests for information from veterans, attorneys and other involved parties; regarding Veteran appointments, and status of delivery of medical reports going to the Veteran's Affairs
- Scheduled compensation and pension examinations and all appropriate diagnostic testing according to claimed or diagnosed conditions; and documented in case management system
- Gathered and recorded information from veteran's military records in regard to claimed and or diagnosed medical conditions to create DBQ questionnaires for examining providers
- Utilized computerized scheduling systems to enter Veteran appointments
- Completed examination invoice with appropriate CPT and ICD 10 codes
- Facilitated transportation for Veterans to travel to and from examination
- Reviewed medical records to assist with examination request from Veteran Affairs
Front Desk Receptionist
Drexel Internal Medicine
02.2012 - 10.2013
- Completed skilled administrative work to support all office staff and operational requirements.
- Prepared patient charts for upcoming appointments
- Verifiy patient insurance coverage, collects patient co-payment, deductible, and patient self-payments
- Gathered information from patient's charts and other medical records to obtain pre-authorizations for diagnostic testing
- Answer and operate busy multi-line office phone, and scheduled patients appointments utilizing Allscripts EMR
- Manually and electronically created referrals for specialty office appointments when required by insurances
- Managed master calendar and scheduled appointments for 15 providers based on optimal patient loads and clinician availability.
- Organized paperwork such as charts and reports for office and patient needs
- Documented patient medical information, case histories and insurance details, utilizing EMR (electronic medical records)
- Verified insurance coverage by telephone and online to guarantee proper reimbursement of benefits and estimate patients' financial responsibilities
- Maintained current and accurate medical records for large internal medicine practice
- Greeted guests at front desk and engaged in pleasant conversations while managing check-in process.
Claims Processor
Equity Staffing Contracting For United Health Care
Horsham, PA
08.2011 - 01.2012
- Prepared insurance claim forms or related documents and reviewed for completeness.
- Calculated medical claims to pay secondary to Medicare
- Utilized various claim and patient information software systems
- Created and assigned correspondence related to claim payment or payment denials
- Approved or denied claims based on benefits and eligibility guidelines
- Analyzed incomplete claims to identify the correct insured member and forwarded to appropriate processing department
- Consistently exceeded production standards set forth by management
- Examined Medicare EOB to determine amount to be paid to claim
Billing Customer Service Representative
Quest Diagnostics
Norristown, PA
01.2010 - 06.2011
- First point of contact for customers calling with inquiries or payments for lab invoices
- Investigated possible errors on patient bill/invoice, and issued refund when appropriate; or resubmitted to insurance company
- Performed manual and electronic billing functions
- Explained billing statements, Medicare and 3rd party insurance EOBs to patients and providers
- Processed credit card payments and assisted patients with setting up payment plans and various payment options
- Maintained patient information in accordance to strict HIPPA regulations
- Investigated coordination of benefits often utilizing the birthday rule.
Customer Care Representative
Praxaire Healthcare Services
02.2004 - 08.2009
- Created new customer accounts by collecting demographics and insurance information and recording in patient information software
- Gathered patient information from patient and or healthcare providers requesting delivery or service of Durable Medical Equipment or Oxygen tanks and supplies
- Verified insurance benefits and obtain pre-authorization for DME
- Documented summaries of calls, tracked call ends and maintained phone logs
- Preserved revenue streams by utilizing strong communication and negotiation skills, offering refunds as last resort to maintain customer satisfaction.
- Achieved and consistently exceeded revenue quota through product and service promotion during routine calls.
Transportation Coordinator
Network Ambulance
09.2002 - 03.2004
- Facilitated transportation from Lower Buck's Hospital to patients residence or other treatment facilities when needed
- Interviewed patients and reviewed patient's medical chart to determine appropriate level of transport, while ensuring medical necessity with insurance company
- Provided support to billing department by investigation of patient's medical records for medical necessity and other pertinent information
- Created, filed and maintained appropriated medical forms to be forwarded to the billing department
- Completed Certificate of Medical Necessity (CMN) for Medicare billing purposes
Member Services Representative
Independence Blue Cross
Philadelphia, PA
09.1999 - 03.2002
- Educated and assisted members regarding insurance products, policies, procedures and claims
- Verified eligibility, benefits, and policy limitations and guidelines for members and healthcare providers.
- Assisted healthcare providers and pharmacies with the pre-certification process for procedures or medications
- Researched and reprocessed medical claims with corrected dates of service, ICD, and CPT coding
- Utilized various information screens to assist callers with inquiries
- Explained EOBs to members regarding patient responsibility for balances owed to healthcare providers
- Researching of claims to ensure quality, correct payment, and eligibility.
Education
GED -
Temple University
Philadelphia08.1999
Medical Billing And Medical Office
Pennco Tech
Bristol, PA06.1999
Skills
- Medical Terminology
- ICD 10 and CPT coding
- Patient Scheduling
- EMR ( ECW, ATHENA, ALLSCRIPTS, EPIC
- Insurance claims
- Medical office administration
- Case Management
- Typing 80wpm
- Diagnostic Equipment Expertise
- Payment collection
- Patient Assessments
- Policy analysis
- Prior Authorization Processing
- Referral Coordination
- Insurance Terminology
- Insurance Plan Verification
- Patient Contact
- Electronic Authorization Processing
- Payor Procedures
- Deductible and Co-Pay Calculation
- CPT Coding
- Payment Plan Options
- Schedule Patients
- Insurance Authorizations
Timeline
Referral Coordinator
Central Florida Kidney Specialist
01.2023 - 12.2023
Insurance Verification Specialist
West Orlando Pediatrics
10.2022 - 03.2023
Case Specialist
QTC MANAGEMENT
01.2015 - 12.2020
Front Desk Receptionist
Drexel Internal Medicine
02.2012 - 10.2013
Claims Processor
Equity Staffing Contracting For United Health Care
08.2011 - 01.2012
Billing Customer Service Representative
Quest Diagnostics
01.2010 - 06.2011
Customer Care Representative
Praxaire Healthcare Services
02.2004 - 08.2009
Transportation Coordinator
Network Ambulance
09.2002 - 03.2004
Member Services Representative
Independence Blue Cross
09.1999 - 03.2002
GED -
Temple University
Medical Billing And Medical Office
Pennco Tech