Nelda Reyes
EDNA,TX
Summary
Seasoned Utilization Review Specialist with background in healthcare management and clinical care. Experience includes performing utilization reviews, ensuring compliance with health insurance requirements, and coordinating patient services. Strengths lie in knowledge of medical procedures, strong analytical skills, and ability to communicate effectively with medical professionals. Noteworthy contributions include improving efficiency of review processes and fostering relationships between healthcare providers and insurers.
Overview
22
22
years of professional experience
Work History
Utilization Review Specialist
COMMONSPIRIT/ST LUKES HEALTH
HOUSTON , TX
02.2019 - Current
- Maintained accurate documentation related to all activities performed in compliance with departmental policies.
- Provided education and guidance on utilization management principles to internal staff members.
- Served as a liaison between payers, providers, patients and families concerning authorization decisions.
- Attended relevant meetings and conferences related to Utilization Review activities.
- Referred cases to secondary review for failure to meet criteria.
- Assisted in developing and implementing training programs for new utilization review staff.
- Documented all utilization review activities, findings, and decisions in patient records and databases.
- Utilized computerized Resource and Patient Management System (RPMS) and Electronic Health Record (EHR) system.
Claims Specialist
Griffin Global Systems
05.2017 - 09.2017
- Work from home follow up claims handling, AR adjustments, Medicaid review
- Working remotely from home to obtain a clean AR work list for the provider/hos-pital
- Reviewed and analyzed insurance claims to determine validity, completeness, accuracy, and eligibility for payment.
- Processed payments for valid claims according to established procedures.
- Assisted with filing appeals on denied claims with insurance companies.
- Performed periodic audits of closed files to ensure accuracy of documentation and compliance with regulations.
- Evaluated financial information provided by claimants in order to process payments quickly and accurately.
- Collaborated with other departments within the organization to resolve issues related to claims processing.
- Researched and reviewed information to determine validity of insurance claims and contacted companies and customers about decisions.
Regional Team Coordinator
Community Health Systems
Houston , TX
12.2013 - 03.2017
- Difficult account review for billers, payer source set up, appeals, billing edits/completion.
- Work from home on Medicaid/HMO and commercial insurances.
- Developed and implemented team-building activities to promote collaboration among staff members.
- Organized and scheduled team meetings, conference calls and video conferences.
- Created weekly reports on team performance metrics and distributed them to stakeholders.
- Provided administrative support for the team, such as creating presentations, taking notes during meetings, preparing agendas and maintaining records of key decisions.
- Analyzed project data to identify areas of improvement in team processes.
- Tracked project tasks using a variety of project management software tools.
- Assisted in resolving conflicts between staff members through effective communication strategies.
Certified Nursing Assistant
OMNI STAFFING
Moses Lake , WA
01.2013 - 06.2013
- Assisted patients with activities of daily living such as bathing, grooming, and dressing.
- Provided basic patient care by taking vital signs, measuring height and weight, and recording intake and output.
- Reported changes in patient condition to registered nurse or physician.
- Transported patients to treatment units, using wheelchair or strher.
- Turned and repositioned bedridden patients on a regular schedule to prevent bedsores.
- Answered call lights promptly and responded to patient needs accordingly.
- Observed patients for any changes in their physical or mental condition.
- Served meals to patients in their rooms and assisted with feeding when needed.
- Collected specimens for testing purposes upon request from physicians or nurses.
- Administered medications as directed by registered nurse or physician.
- Assisted with ambulation of patients utilizing appropriate equipment safely.
- Performed housekeeping duties such as changing linens and cleaning bathrooms when necessary.
- Took temperature readings orally or rectally as instructed by the RN or MD.
- Provided emotional support to family members regarding end-of-life decisions.
- Provided comfort measures such as back rubs and positioning pillows for added comfort.
Hospitality Team Member
Odessa Hospital
Odessa , WA
09.2011 - 10.2012
- Personal ADL's, Hospital Registration
- Nursing Assistant
- Personal care, such as bathing, clothing, feeding, hospital registration/data entry.
- Greeted guests in a friendly and professional manner.
- Provided customer service to ensure guest satisfaction.
- Handled incoming calls, answered questions, and responded to complaints promptly.
- Maintained cleanliness of dining area, kitchen, and other areas of the restaurant.
- Organized tables according to customer preferences.
- Communicated effectively with team members to ensure smooth operations during peak hours.
- Restocked supplies as needed throughout shift.
- Followed health department guidelines when handling food items.
- Resolved customer disputes in a timely fashion.
- Monitored inventory levels and replenished stock as needed.
- Attended team meetings regularly to discuss operational issues.
LEAD REIMBURSEMENT SPECIALIST/INTERPRETER
MEDICAL BILLING ASSOCIATES
Sedalia , MO
04.2007 - 04.2010
- Job duties: I did medical reimbursement with the focus of worker's compensation, Medicaid, medical claims, and collections.
- I used my customer service to be an account advocate for the patients.
- I utilized my previous knowledge to excel in my position, to work up to a lead account specialist.
- Coordinated with providers to resolve payment discrepancies or other billing issues.
- Reviewed medical documentation to evaluate the accuracy of submitted claims for reimbursement purposes.
- Responded promptly to inquiries from internal staff members regarding reimbursement policies and procedures.
- Provided guidance and assistance to other departments in understanding the complexities of healthcare reimbursement systems.
- Obtained maximum reimbursement by following up on unpaid claims and reviewing monthly aging reports.
LEAD ACCOUNT SPECIALIST/INTERPRETER
HRS ERASE INC
Lees Summit , MO
06.2002 - 06.2005
- JOB DUTIES: I WORKED MYSELF UP TO BE A LEAD IN MEDICAL REIM-BURSEMENT
- I FOCUSED ON WORKER'S COMPENSATION/MEDICAID ANDMEDICAL CLAIMS
- I COLLECTED ON HIGH DOLLAR ACCOUNTS FOR VARI-OUS HOSPITALS IN THE GREATER KANSAS CITY AREA
- I ALSO DID ADVO-CATE WORK TO HELP THE LESS FORTUNATE GET THIER BILLING PAID BYMEDICAID, MEDICARE OR CHARITY FOUNDATIONS
Education
HIGH SCHOOL DIPLOMA - GENERAL
RAYMONDVILLE HIGH SCHOOL
Raymondville, TX05.1997
AA -
Lone Star College System
Kingwood, TXSkills
- Bilingual
- Microsoft Outlook/Word/Excel/Powerpoint
- HomeCare-HomeBase
- Emdeon Clearinghouse
- Passport Program
- Sorian Financials
- Epic
- Availity
- Payor Web Portal
- Meditech
- Careport
- 55-75 WPM
- Team Collaboration
- Task Prioritization
- Professionalism
- Workflow improvement
- Train users
- Professional Demeanor
- Attention to Detail
- Analytical Thinking
- Reliability
- Problem-solving abilities
- Multitasking
Timeline
Utilization Review Specialist
COMMONSPIRIT/ST LUKES HEALTH
02.2019 - Current
Claims Specialist
Griffin Global Systems
05.2017 - 09.2017
Regional Team Coordinator
Community Health Systems
12.2013 - 03.2017
Certified Nursing Assistant
OMNI STAFFING
01.2013 - 06.2013
Hospitality Team Member
Odessa Hospital
09.2011 - 10.2012
LEAD REIMBURSEMENT SPECIALIST/INTERPRETER
MEDICAL BILLING ASSOCIATES
04.2007 - 04.2010
LEAD ACCOUNT SPECIALIST/INTERPRETER
HRS ERASE INC
06.2002 - 06.2005
HIGH SCHOOL DIPLOMA - GENERAL
RAYMONDVILLE HIGH SCHOOL
AA -
Lone Star College System
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