Nicole Diaz
Bridgeport,CT
Summary
Organized and motivated employee eager to apply time management and organizational skills in various environments. Seeking opportunities to expand skills while facilitating company growth. Knowledgeable patient representative offers demonstrated skills in case management and service coordination. Expertly handles complaints, inquiries and service questions to meet patients' access needs and correct problems related to care. Well-versed in policies, procedures and standards
Overview
20
20
years of professional experience
Work History
Patient Financial Counselor
Silver Hill Hospital
03.2024 - Current
- Implement reports in the Eclipsys system and uses WQM to follow up on past due accounts
- Process refund checks to guarantors and third parties for overpaid accounts
- Contact insurance companies to verify patient’s insurance coverage
- Handles reconciliation and write-up for approval for accounts that need to be transferred to collection agencies due to non-refusal of payment
- Review costs, insurance coverage and payment requirements
- Reconciles and applies contractual allowances and provides an account summary for assigned patient account
- Runs monthly trial balance and maintains current with aging of accounts, alerting manager of any potential issues.
Managed Care Coordinator
Horizon Blue Cross Blue Shield - Temp
06.2023 - 03.2024
- Prepare, document and route cases in appropriate system for clinical review
- Authorize services based upon scripts or algorithms used for pre-review screening
- Conduct utilisation management review activities that require interpretation of clinical information
- Assists members with finding providers
- Resolve problems and answer questions regarding services and filing claims appeals
- Assists members making appointments with their PCP, specialists, and/or transportation, etc
- Process PCP, demographic changes, and new ID cards
- Triage and distribute referrals from Member Services and providers.
Prior Authorization Specialist
LanceSoft (CVS Health/CareMark) -Temp
12.2022 - 03.2023
- Discuss medications, insurance, and prior authorization documents with patients
- Get prior authorization approval from insurance firms and nurse managers
- Appeal insurance companies after prior authorization refusals
- Assess accounts for completeness and accuracy
- Document account activity using correct medical and billing codes
- Follow up on missing or incorrect information so patients receive the right reimbursement.
Claim Specialist
Titanium Healthcare
08.2019 - 06.2022
- Address payer requests and discrepancies, facilitating the prompt resolution of pending claims
- Update codes, redistributing revenue, requesting rebills, and updating denial modules
- Resolve accounts with discrepancies to ensure payment compliance
- Prepare and submit effective appeals for various denials, including contract underpayments, billing issues, and payor error.
Reimbursement Analyst
Cooper Genomics
04.2019 - 08.2019
- Accounts Receivables Analysis
- Bill charges for completed PGT lab tests based on test requisition form and laboratory final report
- Assist Client Services team with resolution of patient billing questions (ticketed via ZenDesk system)
- Communicate finding of payer trends to Manager
- Post payments, denials, and correspondence from all sources in the billing system
- Monitor and update lab trackers to reconcile charges and ensure cases are billed.
Prior Authorization Specialist
United Healthcare
04.2014 - 10.2018
- Obtain insurance prior authorization for patient prescriptions, treatments, procedures etc
- Prepare case files for physician review via Physician Consultant Services or Medical director
- Document clinical information regarding individual reviews in SOAP format
- Assist Operation teams with processing externally referred patients
- Appeal prior authorization denials and help facilitate peer-to-peer reviews as needed
- Escalate any issues or concerns to the appropriate department or manager as necessary
Customer Service Representative
Optimum
05.2013 - 04.2014
- Provide routine customer service billing support and transaction issues
- Maintain effective working knowledge of collection processes
- Identify and handle upgrade and retention opportunities
- Meet delivery, technical, productivity, and process goals
- Provide professional, courteous, responsive, and accurate service to our customers.
Medical Record Reviewer
Outcomes Health Information Solution
04.2012 - 06.2012
- Scan relevant components of the medical record to support reviews performed
- Maintain communication lines with assigned advocate
- Complete required training, test, and quality assessments
- Communicate with care provider offices, clinics, hospitals, and other clinical facilities
- Travel to medical facilities to complete review services.
Customer Service Representative
People's United Bank
03.2009 - 12.2011
- Process customer cash deposits and withdrawals, cheques, transfers, bills and credit cards etc
- Open accounts and savings plan and purchasing bonds
- Sell travellers' cheques, foreign currency, and money orders
- Inform customers of available banking products and services to address their needs.
Technical Support
Affinion Group
02.2007 - 02.2008
- Handle all incoming calls and emails related to customers’ order
- Help our customers with problem or questions about their order
- Help place order by phone for offline member
- Handle fraud inquiries
Medical Assistant
Medical Associates of Danbury Hospital
04.2006 - 01.2007
- Register, update patient information and bills physician charges to patients' accounts
- Schedule appointments as ordered for patients in the office, for testing, or other physicians
- Collect, prepares, and processes specimens as directed by the physician
- Maintain inventory, clean and test medical equipment and supplies.
Behavioral Health Intake Coordinator/Medical Management
Oxford Health Plan/United Healthcare
02.2005 - 04.2006
- Work with nursing, medical, and other disciplines to coordinate care for patients
- Complete pre-certification with insurance companies to authorize patients' hospitalization
- Complete level of care assessments for clients seeking inpatient and outpatient mental health services
- Handle referrals for services, schedules assessments, and/or refer patients to appropriate community resources.
Education
Medical Assisting Program -
Porter and Chester Institute
01.2006
Berkeley College
01.1998
High school diploma -
Bullard Havens Tech
Skills
- Word
- Excel
- PowerPoint
- SharePoint
- Teams
- Outlook
- EMR
- EPIC
- HER
- COVERMYMED
- EPA
- Medical and Insurance Billing systems
- CPT
- ICD-10
- HCPC
- HIPAA
- FDA
- OSHA compliance
- Medicare
- Medicaid
- Dental and Medical Terminology
- Customer Service
- Patient Care
- Case Management
- Documentation
- Communication Skills
- Interpersonal Skills
- Collaboration
- Data Entry and Scheduling
- Detail Oriented
- Utilization review
- Product Knowledge
- Specialty Care
References
Available upon request
Timeline
Patient Financial Counselor
Silver Hill Hospital
03.2024 - Current
Managed Care Coordinator
Horizon Blue Cross Blue Shield - Temp
06.2023 - 03.2024
Prior Authorization Specialist
LanceSoft (CVS Health/CareMark) -Temp
12.2022 - 03.2023
Claim Specialist
Titanium Healthcare
08.2019 - 06.2022
Reimbursement Analyst
Cooper Genomics
04.2019 - 08.2019
Prior Authorization Specialist
United Healthcare
04.2014 - 10.2018
Customer Service Representative
Optimum
05.2013 - 04.2014
Medical Record Reviewer
Outcomes Health Information Solution
04.2012 - 06.2012
Customer Service Representative
People's United Bank
03.2009 - 12.2011
Technical Support
Affinion Group
02.2007 - 02.2008
Medical Assistant
Medical Associates of Danbury Hospital
04.2006 - 01.2007
Behavioral Health Intake Coordinator/Medical Management
Oxford Health Plan/United Healthcare
02.2005 - 04.2006
Medical Assisting Program -
Porter and Chester Institute
Berkeley College
High school diploma -
Bullard Havens Tech
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