Raelena Grijalva

• Lead and develop a team of approximately 20 patient access specialists supporting oncology and infusion authorization operations.

• Conduct annual performance evaluations, quality reviews, coaching sessions, corrective actions, and employee development planning.

• Participate in recruitment, interviewing, onboarding, and training of new staff members.

• Oversee daily operations for infusion authorizations, appeals, co-pay assistance programs, patient assistance programs, billing discrepancy resolution, denial management, and payer escalations.

• Monitor departmental productivity metrics, quality standards, and operational performance to ensure service level expectations are achieved.

• Serve as a primary resource for staff and cross-functional partners regarding workflow interpretation, escalation management, payer requirements, and operational processes.

• Collaborate with clinical, pharmacy, contracting, revenue cycle, financial counseling, and scheduling teams to resolve complex authorization and reimbursement challenges.

• Contribute to process improvement initiatives focused on reducing denial rates, improving work queue performance, and enhancing patient access to care.

• Develop workflow guidance, operational tip sheets, training resources, and communication tools to support team consistency and compliance.

• Support strategic initiatives, including authorization automation efforts and workflow optimization projects designed to improve operational efficiency.

• Implemented process improvements that increased operational efficiency within the patient access team.
• Mentored team members in conflict resolution strategies to enhance patient interactions and satisfaction.
• Established strong relationships with insurance providers through effective communication channels to expedite claim processing activities when necessary.
• Facilitated cross-functional collaboration between departments to streamline processes and provide seamless patient care services.
• Enhanced patient satisfaction with improved communication strategies and timely resolution of issues.
• Conducted regular performance reviews for staff members, providing constructive feedback and setting goals for future growth and development.
• Stayed calm under pressure to and successfully dealt with difficult situations.
• Established and maintained effective communication with staff, physicians and community organizations to promote high quality patient care.

• Actively listened to customers, handled concerns quickly and escalated major issues to supervisor.
• Drove operational improvements which resulted in savings and improved profit margins.
• Created spreadsheets using Microsoft Excel for daily, weekly and monthly reporting.
• Increased customer satisfaction by resolving financial questions or billing issues.
• Saved patients money by implementing cost-saving programs to patients who qualified for financial or co-pay assistance
• Tracked all pending authorizations to resolve discrepancies and avoid revenue loss.
• Maintained confidentiality of patient finances, records and health statuses.
• Presented insurance options to customers in order for them to continue care with current oncologist
• Communicated effectively with staff, including members of operations, finance and clinical departments.
• Coordinated with contracting department to resolve payer issues.
• Followed up on denied and unpaid claims to resolve problems and obtain payments.
• Delivered timely information to insurance representatives to resolve common and complex issues.
• Guided office staff on how to effectively complete prior authorization forms and appeals documentation to achieve positive results.
• Maintained strong knowledge of basic medical terminology to better understand services and procedures.
• Made contact with insurance carriers to discuss policies and individual patient benefits.
• Posted payments to accounts and maintained records.
• Communicated effectively with staff members of operations, finance and clinical departments.
• Reviewed outstanding requests and redirected workloads to complete projects on time.
• Coordinated with insurance providers to verify customer's policy benefits in relation to claims.
• Accomplished multiple tasks within established timeframes.
• Cross-trained existing employees to maximize team agility and performance.
• Delivered feedback to decision-makers regarding employee performance and training needs.
• Acted as a team leader in group projects, delegating tasks and providing feedback
• Proven ability to learn quickly and adapt to new situations
• Worked well in a team setting, providing support and guidance
• Used critical thinking to break down problems, evaluate solutions and make decisions
• Self-motivated, with a strong sense of personal responsibility
• Organized and detail-oriented with a strong work ethic

• Identified healthcare resources and programs for patients unable to meet financial obligations.
• Liaised between patient, doctor and insurance provider to smooth claims processes.
• Contacted insurance providers to obtain key information regarding patient benefits and to submit documentation for accounts.
• Conducted interviews with patients and family members and answered questions regarding insurance benefits.
• Screened patients with financial needs to determine assistance choices.
• Updated accounts with latest patient, payment and insurance information.
• Followed up with patients and families to obtain additional information.
• Negotiated settlements and payment plans.
• Worked with medical teams, patients and families to implement effective treatment plans.
• Documented case notes daily and coordinated follow-up for seamless case management.
• Organized clinical documentation, treatment plans, and referrals.
• Performed duties in accordance with all applicable standards, policies and regulatory guidelines to promote safe working environment.
• Developed team communications and information for meetings.
• Facilitated communication between patients and various departments and staff.
• Offered simple, clear explanations to help clients and families understand hospital policies and procedures.
• Helped address client complaints through timely corrective actions and appropriate referrals.
• Demonstrated respect, friendliness and willingness to help wherever needed.
• Performed duties in accordance with applicable standards, policies and regulatory guidelines to promote safe working environment.
• Maintained energy and enthusiasm in fast-paced environment.
• Proved successful working within tight deadlines and fast-paced atmosphere.
• Offered friendly and efficient service to customers, handled challenging situations with ease.
• Developed and maintained courteous and effective working relationships.
• Contacted insurance providers to obtain key information regarding patient benefits and to submit documentation for accounts
• Documented details regarding contact with patients, providers and other individuals in system
• Conducted interviews with patients and family members and answered questions regarding insurance benefits
• Identified healthcare resources and programs for patients unable to meet financial obligations
• Liaised between patient, doctor and insurance provider to smooth claims processes

• Reviewed documentation for accuracy and assessment of necessity.
• Reviewed authorizations from payer to determine approved or denied items.
• Submitted for prior authorization with required documentation to appropriate funding source.
• Maintained consistent follow-up on status of prior authorization requests.
• Gathered records pertinent to specific problems, reviewed for completeness and accuracy and attached records to correspondence as necessary.
• Quickly learned new skills and applied them to daily tasks, improving efficiency and productivity.
• Demonstrated respect, friendliness and willingness to help wherever needed.
• Completed form letters in response to requests or problems identified by correspondence.
• Communicated with patients, ensuring that medical information was kept private.
• Managed time efficiently in order to complete all tasks within deadlines
• Strengthened communication skills through regular interactions with others
• Paid attention to detail while completing assignments

• Conducted day-to-day administrative tasks to maintain information files and process paperwork.
• Examined claims forms and other records to determine insurance coverage.
• Read over insurance policies to ascertain levels of coverage and determine whether claims would receive approvals or denials.
• Delivered exceptional customer service to policyholders by communicating important information and patiently listening to issues.
• Researched claims and incident information to deliver solutions and resolve problems.
• Identified insurance coverage limitations with thorough examinations of claims documentation and related records.
• Organized, planned, and documented materials for Medi-Cal claims.
• Processed and finalized appeals and grievances within agreed-upon turnaround time.
• Provided outreach for additional information for appeals and grievances.
• Submitted verbal and written notification to members and providers.
• Remained knowledgeable regarding company policies and procedures and current developments within operational departments.
• Entered appeal requests in appeals module.
• Quickly learned new skills and applied them to daily tasks, improving efficiency and productivity.
• Identified insurance coverage limitations with thorough examinations of claims documentation and related records