Summary
Overview
Work History
Education
Skills
Certification
Timeline
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Nicolette Riojas

Nicolette Riojas

San Antonio,TX

Summary

Experienced and ambitious Patient Care Coordinator with a strong background in the medical field, including front office and back office roles. Also, gained valuable knowledge as a licensed insurance agent in P&C for 3 years. Dedicated to expanding expertise by consistently completing necessary continuing education requirements. Unwavering drive to provide exceptional patient and customer experiences fuels determination to achieve personal and team goals.

Overview

13
13
years of professional experience
1
1
Certification

Work History

Patient Care Coordinator

Centene
06.2024 - 01.2025
  • Managed sensitive patient information with strict adherence to HIPAA guidelines, maintaining confidentiality and privacy at all times.
  • Delivered outstanding customer service by resolving concerns, answering questions, and ensuring patient satisfaction.
  • Enhanced patient satisfaction by efficiently scheduling appointments and managing patient flow.
  • Enhanced patient satisfaction by coordinating timely care and addressing individual needs.
  • Evaluated patient satisfaction surveys to pinpoint improvement areas and apply modifications.
  • Optimized resource allocation, ensuring that necessary medical supplies were always available for patient care.
  • Streamlined completion of order requests by managing patient needs and DME paperwork.
  • Analyzed Medicaid and Medicare guidelines to assess DME requests.
  • Processed referrals for DME companies to obtain needed medical devices.
  • Developed connections within the healthcare community, broadening available patient referral services.
  • Resolved patient concerns and complaints with empathy and professionalism.
  • Provided excellent customer service to patients and medical staff.
  • Resolved customer complaints using established follow-up procedures.
  • Provided guidance to ensure correct handling of in-home medical tools.
  • Oversaw complete lifecycle management of assigned caseloads.
  • Collaborated to redistribute and resolve pending workloads effectively.

Licensed Insurance Agent/Customer Service

USAA
12.2020 - 03.2023
  • Facilitate the Property & Casualty (P&C) member experience by answering inbound and/or outbound phone calls, emails, and/or other contacts from members
  • Apply proficient knowledge of personal lines' insurance to assist members with moderately sophisticated quotes, binding new business, rating, policy, billing, payment, underwriting, contract and coverage provisions, and premium changes for insurance products and services
  • Responsible for the respective trailing documents for all states and/or international requirements and offerings
  • Identify, assess, and understand member needs while consistently providing complete and accurate advice and solutions for insurance products and services
  • Provides detailed issue diagnosis while minimizing transfers, customer concerns and call backs
  • Use the tools and resources available to support members with some assistance
  • Optimally operates in a contact center environment and navigates multiple systems/programs while maintaining an engaging member interaction that occurs across multiple channels
  • Maintain required Property & Casualty (P&C) license and state registrations
  • Identify and handle existing and emerging risks that stem from business activities and the job role
  • Ensure risks associated with business activities are optimally identified, measured, supervised, and controlled
  • Follow written risk and compliance policies and procedures for business activities

Patient Advocate

SAGE Bariatric
06.2019 - 07.2020
  • Guided new patients through essential information about bariatric surgical procedures.
  • Ensured completion of pre-surgery testing requirements set by insurers and surgeons.
  • Obtains patient medical records, reviews preoperative clinical information and test results
  • Ensure completion of insurance prerequisites before surgery.
  • Set up surgeries following approval from insurers.
  • Verified and updated benefit accumulations to determine out-of-pocket expenses for the surgeon.
  • Schedule any peer-to-peer calls needed if a denial is received
  • Gathered crucial documents to support an appeal upon denial.
  • Answers patient questions before and after surgery, and advocate for patients during every phase of the process

HIM Technician (Remote)

Himagine Solutions
06.2018 - 11.2019
  • Effectively collaborated on remote projects while working from home.
  • Identifying a patient and their medical record to determine appropriate action and determination to be made when cleaning up the name list provided from the Santa Clara Hospital in California
  • Maintained the accuracy, reliability, and integrity of the Enterprise Master Patient database to ensure patient safety for all clinical and financial systems dependent on this data
  • As the analyst I was responsible for maintaining patient identity integrity by using analytical and investigational skills
  • In addition, I utilized multiple tools and systems to coordinate the patient identity story and independently determine and execute action needed to remediate identity discrepancies
  • Responsible for turning in my daily productivity to my team lead and logging my time into Salesforce daily
  • Reading daily emails and communicating through Outlook
  • On occasion was assigned to assist the team lead and QA some of the spreadsheets from other HIM Techs
  • Achieved timely completion of assigned tasks to facilitate pursuit of further responsibilities.
  • Turned in and approved our time sheets every Sunday
  • Finalized project milestones and delivered results by expected time line.

Medical Assistant

BMI Of Texas
05.2018 - 06.2019
  • Facilitated seamless coordination with surgeons, N.P.s, P.A.s, LPCs, dieticians and staff to deliver quality medical care to patients.
  • Manage time, prioritize, and organize work to meet deadlines, ensuring compliance with established policies, regulations in a timely manner
  • Utilized Raintree EMR system and Dr's RX daily.
  • Conducted patient triage.
  • Conducted weekly follow-up calls to monitor patient recovery post-surgery.
  • Occasionally operated remotely to manage task overloads.
  • Administered diagnostic procedures, specializing in EKGs and IDEXA Body Scans.
  • Handled incoming calls and coordinated appointment schedules.
  • Order Labs / Diagnostic testing
  • Ensured timely completion of FMLA and Short-Term Disability documentation.
  • Contributed to patient care by assisting with suture and staple removals, packing and cleaning wounds.
  • Ensured proper filing of all received faxes in corresponding patient folders.
  • Prepared and scanned charts for daily clinic operations.
  • Handled sterilization of medical instruments after each in-office procedure.
  • Assisted with BioTe procedures and product orders.

Utilization Review Specialist

Davis Vision
05.2016 - 05.2018
  • Receive / Review request for eyeglasses and medically necessary contact lenses and as well as low vision aid materials
  • Determine if members qualify for early services based on information submitted by the provider and specific insurance requirements
  • Respond promptly and professionally to requests for prior approvals and medically necessary contact lenses while maintaining performance quality and quantity standards
  • Assure that all proper medical documentation is received for all medically necessary request before submitting review to our Medical Director for approval or denial
  • Notify members, providers and clients as required using approved documents and or via telephone / fax
  • Maintain daily quality numbers and meet deadlines as directed

Case Specialist

QTC Medical Services
09.2014 - 04.2016
  • Answer phones from automated call distribution system ACD
  • Triage daily download of referrals and ensure appropriate worksheets are assigned to corresponding conditions as identified by Veterans Administration
  • Verify appropriate CPT and CLIN codes are assigned to each case
  • Communicate directly with claimants and providers
  • Obtain medical history for specific conditions
  • Determine appropriate examinations, tests and specialists required for each case
  • Schedule appointments for examinees including follow-up appointments and rescheduled appointments
  • Ensure all examinees and providers receive necessary documentation
  • Meet or exceed contract timeliness guidelines in both the scheduling and case management systems
  • Complete other projects and duties as assigned
  • Strong verbal and written communication skills with the ability to critically evaluate and resolve problems

Medical Assistant / Surgical Coordinator

South Texas Surgeons
06.2012 - 07.2014
  • Perform Vitals and Medical History
  • Answer phones and schedule appointments
  • Use of EMR systems MOMS/Amazing charts/Updox/Athena
  • Ordered Labs / diagnostic testing also request and receive authorization from patients PCP and insurance companies
  • Prepared accurate forms for Texas Workers Compensation and FMLA efficiently.
  • Assisted physicians with minor office procedures, such as, I&D's, removal of foreign bodies, staple, and suture removals
  • Packing and cleaning wounds
  • Served as backup for surgery coordinator, managing case scheduling and confirmations.
  • Verified patient benefits for surgical procedures.

Education

Certification in Medical Assistant -

Texas Careers
Lubbock, TX
05.2005

Skills

  • Medical scheduling
  • Case management
  • Insurance Verification
  • EMR Systems
  • Medical Records
  • Epic
  • Customer service oriented
  • Communication skills
  • Negotiation
  • Ability to plan and organize workload
  • Closing Sales
  • Ability to de-escalate
  • Knowledge of Medical Terminology
  • Leadership Skills
  • Capacity to work under pressure
  • Surgery Scheduling
  • Adept at using MS Word, Outlook, Excel and PowerPoint
  • Adept at using Meditech
  • Adept at using Advanced MD
  • Adept at using Raintree

Certification

  • Property & Casualty Insurance License, 12/01/20
  • DEXA Certification, 03/01/23

Timeline

Patient Care Coordinator

Centene
06.2024 - 01.2025

Licensed Insurance Agent/Customer Service

USAA
12.2020 - 03.2023

Patient Advocate

SAGE Bariatric
06.2019 - 07.2020

HIM Technician (Remote)

Himagine Solutions
06.2018 - 11.2019

Medical Assistant

BMI Of Texas
05.2018 - 06.2019

Utilization Review Specialist

Davis Vision
05.2016 - 05.2018

Case Specialist

QTC Medical Services
09.2014 - 04.2016

Medical Assistant / Surgical Coordinator

South Texas Surgeons
06.2012 - 07.2014

Certification in Medical Assistant -

Texas Careers

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Nicolette Riojas