Melisa Duran
Buena Park,CA
Summary
Enthusiastic client services professional with strong background directly interfacing with industry customers. Well-versed in products, services and consumer trends. Dependable achiever committed to holding highest ethical standards and maintaining customer trust.
Overview
8
8
years of professional experience
Work History
Claims/Inbound Call Center Representative
Physicians Medical Group/Optum
San Jose, CA
04.2024 - 12.2024
- Receive calls from provider offices inquiring about a claim.
- Claims a provider's office mailed or inputted in the PMG website.
- Reviewed the claim and provided information, such as whether the claim was denied, paid, rejected, or received.
- Provided payment information, faxed over payment info if needed.
- Reviewed claim information on IDX software and also on QuickCap.
- Received calls from members, healthcare staff, and PMG inquiring about a claim or authorization.
- Provide authorization information by using the Curo application.
Customer Service Representative
CalOptima/OneCare
Orange, CA
09.2023 - 03.2024
- Performs outreach calls to members to receive feedback on how their experience and service are with OneCare.
- Maintains documentation of members' cases within the Facets system.
- Use the Avaya workshop and the Avaya desktop to perform outreach calls and take incoming calls.
- Assists in taking incoming provider calls that come in through our provider line.
- The provider's office will call in to verify a member's eligibility.
- I will then provide information about the member's eligibility, effective date, and member's health plan information.
- Providers will at times ask for the claims address for facility or professional processing purposes.
- Assist with returned mail that was sent out to members and was unable to reach the member.
- I will use Facets to look up the member and contact the member to confirm the address or update the address if needed, and mail out a letter to correct the mailing address provided by the member.
- Complete other duties or projects as assigned.
Claims Examiner
Providence Healthcare
Anaheim, CA
09.2022 - 07.2023
- Responsible for consistently and accurately adjudicating all contracted professional capitated claims, with a fee-for-service carve-out.
- Contracted fee-for-service claims for both Commercial and Senior plans must meet the timeliness and accuracy standards set forth by CMS, the Department of Managed Care, AB1455, and the Claims Department policies and procedures.
Program Support Representative
Amerisource Bergen / Elevate Provider Network
Orange, CA
09.2019 - 05.2022
- Performs routine follow-up with customers regarding incoming questions from phone, email, or fax.
- Daily review of the pharmacy's submitted enrollment packet and supplemental materials, including, but not limited to: State Pharmacy License, PIC License, DEA Registrations, Insurance Policies, and Program Specific Addendums.
- Daily outreach to pharmacies to collect and process licenses and other materials, including, but not limited to: State Pharmacy License, PIC License, DEA Registrations, Insurance Policies, and Program Specific Addendums.
- Primary telephone coverage for managed care, claims processing issues, updates to the network database, creation, and distribution of network materials and communications.
Outreach/Call Center Representative
CareMore/Anthem
Cerritos, CA
06.2018 - 12.2018
- At the Outreach Department, I was responsible for making outbound calls to our elderly patients with diabetes.
- I would call diabetic patients to assist them with scheduling preventive exams. Exam for the yearly eye exam.
- Exam for mammograms for females: mammograms are to be performed every two years, and if a patient needs a mammogram done, I would submit an authorization for the nearest hospital to them.
- Exam for Colonoscopy (Colorectal Cancer Screening): this exam is done every 10 years if the exam was done with a gastroenterologist.
- If the patient needed assistance in completing this exam, I would submit an authorization to the nearest clinic to them.
- The exam for hemoglobin (A1C) and microalbumin, both exams, are to be completed every year.
- If A1C has a test value of 9.0 or higher, patients are to get tested every 3 months.
- With this exam, I would send out a lab slip to the patient, and they were to complete it at their nearest Quest Diagnostics.
- Apart from scheduling exams for patients, I would also assist them with any other questions they had about authorization or if they asked about their medical benefits. I would transfer calls to our Member Services department.
- I would also schedule transportation for our patients, reschedule any appointments they knew they couldn't make, even if the appointment wasn't scheduled by the Outreach department.
- In order to schedule these exams and make outreach calls to our patients, I had to check every file we had on that patient.
- For example, we had three main resources to search for these exams: EMR, which was the main profile for our patients.
- We could see if the patients had any upcoming appointments, when the patients' last doctor's appointment was, and any exam that the patient has ever had.
- Portal - in this source, I could see any authorization that the patient has, had, or if pending.
- Along with the patient, there is a pending exam (eye exam, mammogram, colonoscopy, A1C, or microalbumin).
- PQV (Patient Quick View) - here I was about to see where and when the last exam the patient had was.
- Log our attempts to reach out to the patient. If the patient was reached, we would log the whole purpose of the call, as well as any concerns or questions that the patient had.
- If the patient wanted to be transferred to any other department, we would also log that into the database.
Inbound Call Center Representative
AltaMed
Santa Ana, CA
05.2017 - 01.2018
- Answering calls from patients, pharmacies, and other medical groups daily.
- Scheduling, canceling, and/or rescheduling appointments for patients.
- Request medication refills for patients called in by patients themselves or the pharmacy.
- Work with Outlook to communicate with any of my supervisors or on Skype.
- I work with the EHR program, where I am able to see any information for our patients, doctors, and clinic profiles.
- Able to schedule appointments, request medication refills, and see any medical record for patients in the EHR.
- I used the Client Call system, where I am able to see any calls coming in.
- I can verify if my caller is either an English speaker or a Spanish speaker.
- In this program, I am also able to see how many agents are available, who are in interaction calls, how many calls are waiting to be answered, and how many calls I have answered throughout the day.
- Met the error and accuracy goals set by management.
Education
High School Diploma -
Buena Park High School
Buena Park, CA06.2012
Skills
- Bilingual, Spanish
- 35 WPM/10 Key
- Data entry
- Microsoft programs
- Insurance verification
- HIPAA compliance
- Salesforce experience
- Call center experience
- Medical terminology
- Documentation and reporting
- Appointment scheduling
- CRM software usage
- Processing claims
- SAP experience
- Athena Software
- Facets Software
- IDX software
- Curo
- Healthcare procedures
Languages
Spanish
Native/ Bilingual
Timeline
Claims/Inbound Call Center Representative
Physicians Medical Group/Optum
04.2024 - 12.2024
Customer Service Representative
CalOptima/OneCare
09.2023 - 03.2024
Claims Examiner
Providence Healthcare
09.2022 - 07.2023
Program Support Representative
Amerisource Bergen / Elevate Provider Network
09.2019 - 05.2022
Outreach/Call Center Representative
CareMore/Anthem
06.2018 - 12.2018
Inbound Call Center Representative
AltaMed
05.2017 - 01.2018
High School Diploma -
Buena Park High School