Omayra Molina
Boston,MA
Summary
Seeking full-time employment as a
professional representative in a health care or business setting.
Overview
27
27
years of professional experience
Work History
Acute Care Specialist
BMC HealthNet Plan
Boston, MA
01.2014 - Current
*Right & E fax/Triaging
of Faxes *Entering Inpatients,
Observations, SNF & Rehab requests
*Working closely with hospital Case Managers &
Obtaining initial & concurrent reviews
*Discharge Planning
*Knowledge of some Interqual *Facets *CCMS *CWC.MA/NH
Approval & Denial Letters
*Identifying Trigger diagnosis and making
appropriate Case Management referrals. Submission of SC1 forms
.
Prior Authorization Specialist
BMC HealthNet Plan
Boston, MA
08.2008 - 12.2013
Entering &
processing Home Health Care, Durable Medical Equipment, Outpatient Therapy
request,
*Elective Surgery requests & redirecting out of network & non participating consultations *Knowledge of ICD-9 coding * Knowledge of CPT coding * Knowledge of HCPS coding *Work Flow/Correcting authorizations so claims can be reprocessed & paid out to client *Incoming Calls/Providing accurate and exceptional customer services to BMCHP’s providers *Knowledge of Policies & Procedures *Maintaining knowledge of policies & Network Notifications
*Elective Surgery requests & redirecting out of network & non participating consultations *Knowledge of ICD-9 coding * Knowledge of CPT coding * Knowledge of HCPS coding *Work Flow/Correcting authorizations so claims can be reprocessed & paid out to client *Incoming Calls/Providing accurate and exceptional customer services to BMCHP’s providers *Knowledge of Policies & Procedures *Maintaining knowledge of policies & Network Notifications
Provider Services Representative
Tufts Health Plan
Watertown, MA
10.2001 - 08.2008
Act as a liaison between Tufts Health Plan and providers or billing offices via telephone. Service provider inquiries regarding patient's account . Investigate , and adjust claims. Provide education on Tufts Health plan Policies and procedures to participating physician, hospitals, medical groups, and other ancillary providers. Interpret benefits and eligibility of health plan members.
Medical Claims Processor
Blue Cross & Blue Shield of MA
Quincy, MA
12.2000 - 10.2001
Responsible for accurate /timely daily review of claims and policy provisions to determine appropriate claim eligibility assessments for payment or denial. Responsible for accurate and timely determination of benefits applicable under policy. Research and resolve claims questions.
Customer Service Representative
First Notice Systems
Boston, MA
06.1998 - 12.2000
Answered insurance claims calls. Computer input and processing of all calls/Faxes for personal commercial, and workmen's compensation insurances. I was also responsible for transmittal of accurate information and referral inquiries to branch offices. Assisted in training of new employees.
Education
High School Diploma - undefined
Madison Park Technical Vocational High School
Boston, MA1994
Skills
- Medical terminology expert
- ICD-10 (International Classification of Disease Systems)
- Excellent problem solver
- Hospital inpatient and outpatient records
- Inpatient records coding proficiency
- HCPCS Coding Guidelines
- Understands insurance benefits
- Resourceful and reliable worker
- Close attention to detail
- Office support (phones, faxing, filing)
- Excellent verbal communication
Timeline
Acute Care Specialist
BMC HealthNet Plan
01.2014 - Current
Prior Authorization Specialist
BMC HealthNet Plan
08.2008 - 12.2013
Provider Services Representative
Tufts Health Plan
10.2001 - 08.2008
Medical Claims Processor
Blue Cross & Blue Shield of MA
12.2000 - 10.2001
Customer Service Representative
First Notice Systems
06.1998 - 12.2000
High School Diploma - undefined
Madison Park Technical Vocational High School
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