Norma Diaz-Ayala
Bakerfield,CA
Summary
Highly-motivated with desire to take on new challenges. Strong worth ethic, adaptability and exceptional interpersonal skills.
Overview
21
21
years of professional experience
Work History
Grievance and Appeals Coordinator
Cen-Cal Health
2020.11 - Current
- Review and investigative grievances filed by members
- Requested response to grievance filed and if any needed Medical Records from provider
- Review an filed Appeals requested by member for denied services
- Requested additional information for medical team review and determination
- Member Billing Issues
- Review bills submitted, as needed call provider and provide CenCal Health billing information
- If there is a paid or denied claim on file review this with provider for possible resubmission or review of missed contractual adjustment for positing or write off
Member Service Representative
Cen-Cal Health
2018.01 - Current
- Take member calls
- Up-date member demographics – up-date information & forward to Department of Social services
- Work pharmacy issues – work with pharmacy team to assist members with prescription issues
- File member grievances and complaints – take members complaints and forward to grievance department
- Make member education calls
- Address member inquiries received by voice mail / e-mail with members
- PCP up-dated and or mid-months
Eligibility Clerk
Cen-Cal Health
2016.01 - 2018.01
- Answer provider calls to verify member eligibility / information
- Log Billing Issues – review for log or return to member
- PCP up-dates – receive and process incoming PCP Selections from new members and providers, make provider calls for EPO and or Capacity overrides
- Prepare and distribute Recap Reports monthly
- Back up for Eligibility Clerk
Senior Customer Service Representative
Cottage Health System
2003.09 - 2016.12
- Answer patient calls
- UP-date Patient information on file and or Insurance information
- Verify insurance information and u- dated for billing
- Clear billing edits to assure a clean bill drop
- Address patient inquiries received by phone, e-mail and mail, follow up w/patients on outcome
- Process Community Care Applications for financial assistance
- Run reports for productivity and Maddy reimbursement
- Prepare training procedures and train new employees
- Help walk-in patients with concerns and assist with the process of Community Care Applications
Education
Bachelor of Science - Computer Visualization Technology
ITT Technical Institute
Sylmar, CA2002-09
Associate of Science - Computer Aided Drafting Technology
ITT Technical Institute
Oxnard, CA2001-03
Skills
- Bilingual (Spanish, English)
- Goal oriented
- Fast learner
- Able to multitask
- Responsible
- Case Research
- Effective communication
- Claims Processing Documentation
Timeline
Grievance and Appeals Coordinator
Cen-Cal Health
2020.11 - Current
Member Service Representative
Cen-Cal Health
2018.01 - Current
Eligibility Clerk
Cen-Cal Health
2016.01 - 2018.01
Senior Customer Service Representative
Cottage Health System
2003.09 - 2016.12
Bachelor of Science - Computer Visualization Technology
ITT Technical Institute
Associate of Science - Computer Aided Drafting Technology
ITT Technical Institute
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