Mayra Cardenas
Menifee,CA
Summary
Mayra is professional customer support specialist with extensive experience in data entry in medical/healthcare departments.
Overview
17
17
years of professional experience
1
1
Certification
Work History
Eligibility Specialist
Wollborg Michelson
Menifee, CA
10.2023 - 03.2024
- Processes and maintains eligibility information for routine individual and/or employer groups under direct supervision. Job Responsibilities: Maintains accurate eligibility records for assigned line of business. Enters system eligibility data on a daily basis, including new enrollees, changes, and cancellations. Conducts periodic audits of group eligibility data. Reconciles group eligibility report to monthly statements. Responds to all written and telephone eligibility inquiries from individuals or assigned employer groups. Research information on subscribers to resolve problems and disputes. Maintains quality and production standards as outlined by the department. Assists with special projects.”
Appeals and Grievance Intermediate Representative
Blue Shield of California (Through Capital Staffing)
10.2022 - 07.2023
- Data Entry Assist with telephone inquiries regarding member appeals
- Respond to appeals and grievances and member reconsiderations specific to mandates, AB347, SB282
- Research, review and resolve high level/high priority member grievances, appeals and complaints, while clarifying issues and educating customers in the process
- Interpret and explain health plan benefits, policies, procedures and functions to members and providers
- Administer ongoing grievance tracking, trending, and reporting for assigned grievance
- Effectively manage a caseload and work in a collaborative manner with your team to meet compliance timeframes of three-day TAT in addition to expedited appeal TAT 24 hour.
Covid 19 Rent Relief Program Case Manager
State of CA (Through Tech System)
03.2022 - 10.2022
- Perform primary review, verify document eligibility, validate income, and rent calculations, collect data, and approve payments for applicants of California states
- COVID-19 Emergency Rental Assistance program
- Ensure eligibility is consistent with both state and federal law
- Return 40-60 calls daily for clients checking status on applications.
Appeals & Grievance Coordinator
St. Jude Heritage Healthcare St. Joseph's Health System (Direct)
09.2017 - 08.2021
- Appeals & Grievance Coordinator for Medicare, Medical, CCS, Tricare, Cal optima, and other Government Plans
- Develops timeless for complaint investigations to ensure the reporting is performed on time and complaints are resolved in a timely manner
- Works independently to investigate complaints in compliance with company procedures
- Using designated database and portals
- Triage up to 60 cases daily, Process and assigns cases accordingly by line of business.
Care Review Processor /UMA
St. Jude Heritage Healthcare St. Joseph's Health System (Direct)
04.2007 - 09.2017
- Process, coordinate and review all referral requests
- Approve referrals from the Referral routing guide
- Document all pertinent information in Epic
- Maintain referral pools to ensure turnaround
- Time is three days from date of receipt per policy
- Daily eligibility and benefit checks on referrals to ensure proper handling of cases
- Assure all referrals are maintained within appropriate networks
- Assisted with state audits from FQHC
- Request clinical documentation and accurately complete or forward to the nurse for a higher level of review
- Handle DC calls for assigned teams daily and adhere to department standards for coverage
- Assist with special projects as assigned by management
- Process, coordinate and reviews all patient denial letter
- Attach the correct letter head for the line of business and email, fax and send the member a copy as well as the provider
- Answer voice mails within an hour upon receiving to ensure customer satisfaction is maintained and emails as well
- Assist with special projects as assigned by management
- Helped with the EDSU team as well as prior auth team.
Education
High School Diploma -
Educational Partnership High School
06.1999
Skills
- Pharmacology FEB 2017 Cypress Nurses Development Center Knowledge with: IDX, ALLSCRIPTS, Outlook, and Laser fish, QNXT, UMK2
- Communication skills, phone etiquette, and Medical Terminology and bilingual Spanish
- Type 45 WPM 10-Key Touch
Certification
- Medical Assistant Certification JULY 2006 Regional Occupational Program
- Certified by interpreter services at St. Jude Medical Center
- Pharmacology Nurses Development Center
Timeline
Eligibility Specialist
Wollborg Michelson
10.2023 - 03.2024
Appeals and Grievance Intermediate Representative
Blue Shield of California (Through Capital Staffing)
10.2022 - 07.2023
Covid 19 Rent Relief Program Case Manager
State of CA (Through Tech System)
03.2022 - 10.2022
Appeals & Grievance Coordinator
St. Jude Heritage Healthcare St. Joseph's Health System (Direct)
09.2017 - 08.2021
Care Review Processor /UMA
St. Jude Heritage Healthcare St. Joseph's Health System (Direct)
04.2007 - 09.2017
High School Diploma -
Educational Partnership High School