Summary
Overview
Work History
Education
Skills
References
Timeline
Generic

Melissa Cajigas

Rosemont,IL

Summary

Dynamic healthcare professional with a proven track record adept in care coordination and access and reimbursement. Excelled in developing effective care plans and enhancing patient outcomes through meticulous case management and education. Skilled in Microsoft Office and possesses strong communication abilities, ensuring comprehensive care and support for patients and families.

Overview

9
9
years of professional experience

Work History

LTSS Care Coordinator

Centene Corporation
, Illinois
05.2023 - Current
  • Assessed patient needs, developed individualized plans of care, and monitored outcomes to ensure effective delivery of health care services.
  • Participated in interdisciplinary team meetings by providing input into the development of individualized service plans for each client served.
  • Maintained accurate and confidential patient records in accordance with HIPAA regulations.
  • Provided education to patients and families about disease process and self-care management techniques.
  • Facilitated communication between patients, families, and healthcare teams to ensure coordinated care.
  • Assisted with developing short-term goals based on identified needs while working towards long term objectives established by the patient's physician.
  • Initiated referrals for additional services when indicated by assessment findings.
  • Developed patient education materials and programs to enhance understanding and adherence to treatment plans.
  • Evaluated effectiveness of interventions used throughout the course of treatment; modified strategies as needed based on outcome analysis.
  • Provided case management services including assisting with referrals, authorizations, eligibility verification, and benefits coordination.
  • Collaborated with other healthcare professionals including physicians, nurses and therapists to coordinate optimal patient care outcomes.
  • Maintained current knowledge base regarding evidence-based practice standards related to clinical areas served.

Member Care Coordinator

Blue Cross and Blue Shield
Downers Grove, IL
05.2022 - 05.2023
  • Work in partnership with members, providers of care, and community resources to develop and implement the plan of care, and achieve stated goals.
  • Adhere to professional standards as outlined by protocols, rules, and guidelines, meeting quality and production goals.
  • Prepare member and/or caregiver for discharge from a facility to home, or for transfer to another healthcare facility, to support continuity of care.
  • Develop, monitor, and evaluate effectiveness of the care management plan, assess adherence to care plan to ensure progress to goals and adjust and reevaluate as necessary
  • Deliver education to include health literacy, self-management skills, medication plans, and nutrition.
  • Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions.
  • Condenses complex issues into simple solutions to improve the member experience.
  • Utilize clinical proficiency, claims knowledge/analysis, and comprehensive knowledge of the healthcare continuum to assess, plan, implement, coordinate, monitor, and evaluate medical necessity, options, and services required to support members in managing their health, chronic illness, or acute illness.

Precerification Coordinator/Clinical Educator

Illinois Bone and Joint Institute
Glenview, IL
10.2015 - 10.2022
  • Extensive knowledge in biologics and the prior authorization process.
  • Completes all tasks within the process of a prior authorization, including appeals, registering for copay cards, and communicating with mandatory specialty pharmacies.
  • Identified opportunities for improvement within the precertification process and recommended solutions accordingly.
  • Knowledgeable with payer terminology, including but not limited to insurance claims, claim denials, overrides, quantity exceeded, etc.
  • Work closely with pharmacies and insurance companies.
  • Demonstrate and apply knowledge of medical terminology, and high proficiency in general medical office procedures, including HIPAA regulations.
  • Communicate any insurance changes or trends among the team.
  • Maintains a level of productivity suitable for the clinical team.
  • Managed intake of new claims and performed routine follow-ups.
  • Explained reasons behind application denials and recommended further action.
  • Ensured compliance with all HIPAA regulations pertaining to protected health information.
  • Educate patients on drug therapy and the precertification process.
  • Educate the patient on the individual pharmaceutical nurse ambassador program when needed.
  • Extensive knowledge of ICD-10 codes pertaining to rheumatology.
  • Verified insurance eligibility, coverage levels, and benefit parameters prior to submission of precertification requests.
  • Resolved any discrepancies identified during the precertification process.
  • Collaborated with multi-disciplinary staff to improve overall patient care and response times.

Certified Medical Assistant Contracted Speaker

Lilly Lecture Bureau
Illinois
05.2019 - 05.2021
  • Delivered requested presentation using information, audio-visual aids, and other presentation materials approved by Lilly
  • Maintained familiarity with the presentation materials, with the prescribing information for any Lilly drugs addressed by the presentation materials, and with other materials received in training
  • Facilitated programs nationally and virtually to groups of healthcare providers that provided an overview of Lilly's support programs and how the staff can aid patients started on Taltz and Olumiant
  • Delivered presentations either in person or through virtual platforms using approved programs to further educate on access program available to patients
  • Within the presentation, providers and support staff were educated on how to use the patient assistance program, fill out forms, and utilize the hub to the best of their ability.
  • Provide excess education on how to troubleshoot any issues that may arise with denials from payers.

Education

Bachelor of Science - Nursing

Chamberlain College of Nursing
Chicago, IL

Medical Assisting -

Lincoln College of Technology
Melrose Park, IL

Skills

  • Proficient in Microsoft Office applications
  • Knowledge of medical and claims processing terminology
  • Excellent written/verbal communication to include providing clear instructions
  • Advocacy and counseling
  • Claims processing
  • Buy and bill process
  • Knowledge of Medicare Parts A, B, C and D
  • Eligibility procedures
  • Strong communication skills
  • Care coordination
  • Problem-solving
  • Multidisciplinary team collaboration
  • Patient education
  • Client relationship management

References

References available upon request.

Timeline

LTSS Care Coordinator

Centene Corporation
05.2023 - Current

Member Care Coordinator

Blue Cross and Blue Shield
05.2022 - 05.2023

Certified Medical Assistant Contracted Speaker

Lilly Lecture Bureau
05.2019 - 05.2021

Precerification Coordinator/Clinical Educator

Illinois Bone and Joint Institute
10.2015 - 10.2022

Bachelor of Science - Nursing

Chamberlain College of Nursing

Medical Assisting -

Lincoln College of Technology

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Melissa Cajigas