Rebecca Calles
Chino,CA
Summary
Proven Sr. Case Manager at Kaiser Permanente, adept in care coordination and enhanced member advocacy through efficient case resolution and documentation. Leveraged problem-solving and organizational skills to exceed compliance standards, demonstrating a commitment to patient privacy and cross-cultural sensitivity.
Overview
13
13
years of professional experience
Work History
Sr. Case Manager
Kaiser Permanente
Corona, CA
10.2022 - Current
- Managing the organization's Grievance, Appeal, and External Review process.
- Investigates all complaints, grievances, and appeals, including collection of appropriate documentation.
- Partner with and outreach to internal staff, other MS Departments, managers, and physicians to resolve issues as quickly as possible.
- Processing cases in an organized and timely fashion to stay in compliance timeframe.
- Responds to members, their physicians, and authorized representatives regarding the Health Plan's determination.
- Prepares all cases in accordance with regulations, compliance standards, and policies and procedures.
- Participates in departmental meetings, trainings, and unit self-audits as requested.
Sr Case Manager
Artech LLC/Kaiser Permanente
Rancho Cucamonga, CA
01.2022 - 10.2022
- Participate in managing the organization's Grievance, Appeal and External Review process
- Investigation and response of all issues, including collection of appropriate data, preparation and presentation of documents to decision makers
- Partner with and outreach to internal staff, other MS Departments, managers and physicians to resolve issues as quickly as possible
- Meets timeframes for performance while balancing the need to produce high quality work related to complex and sensitive member issues
- Accountable for investigation and response of all issues, including collection of appropriate data, preparation and presentation of documents to decision makers
- Protected patient data in alignment with HIPAA privacy protocols
Financial Clearance Specialist
City of Hope
Irwindale, CA
01.2021 - 01.2022
- Obtaining Authorizations from various insurance carriers
- Referral Coordination
- Verifying with insurance companies what needs pre-certifications
- Performing pre-registration verification of coverages
- Processing Authorizations from multiple work ques
- Submitting authorization requests to various payors
- Managing incoming faxes and various emails
- Commended for timeliness and accuracy in all documentation, from initial contact to account closeout
- Verified documents and associated records to catch and resolve discrepancies
- Gathered community resources and coordinated referrals to obtain services
- Verifying patient's insurance coverages and creating Hospital Account Summary
Front Desk Medical Receptionist
Concentra Urgent Care
Ontario, CA
10.2019 - 03.2020
- Patient Registration
- Checked insurance
- Registered Drivers for DOT exam
- Answering Phones
- Confirming next day appointments
- Scheduling patient appointments
- Filing
- Mail sorting
- Chart Prepping
- HIPPA
- EMR
Medical Assistant
Golden Shore Medical Group
Ontario, CA
03.2016 - 01.2019
- Assisted physicians by preparing patients for procedures, including EKGs, phlebotomy, glucose testing and pulmonary function tests
- Conducted patient interviews to gather health history, vital signs and information about current medical issues
- Oversaw patient registration, insurance verification, form completion and appointment scheduling to maintain operational efficiency
- Interviewed patients to verify information, record medical history and confirm purpose of visit
- Scheduled appointments for patients via phone and in person
- Processing Referrals
- Working with medical record requests (CHAMPS)
- Maintained a clean, healthy and safe environment
- Performed clerical duties, such as word processing, data entry answering phones and filing
- HIPPA/JCAHO
- EMR
Front Desk Clerk
Molina Medical Group
Ontario, CA
06.2015 - 03.2016
- Scheduling patient appointments
- Registration of patients appointments
- Insurance eligibility checks
- Answering Phones
- Working with Medical records (CHAMPS)
- Confirming appointments
- HIPPA/JCAHO
- EMR
Medical Assistant
My Family Medical Group
Chino, CA
11.2011 - 06.2015
- Assisted physicians by preparing patients for procedures, including EKGs, phlebotomy, glucose testing and pulmonary function tests
- Conducted patient interviews to gather health history, vital signs and information about current medical issues
- Communicated with patients by phone and via written correspondence
- Experience in assisting with minor procedures such as biopsies and cyst removals
- Visual/Audio Acuity
- Pace Maker Checks
- EMR
- Splinting
- HIPPA/JCAHO
Education
Phlebotomy -
American University Of Medical Technology
Ontario, CA11.2011
Medical Assistant -
Everest College
Ontario, CA10.2011
High School Diploma -
Don Antonio Lugo High School
Chino, CA05.2009
Skills
- Member Advocacy
- Care Coordination
- Telephone etiquette
- EMR Charting (EPIC)
- Efficient and reliable team player
- Bilingual (Spanish)
- Typing of 50 WPM
- Cross-cultural sensitivity
- Technologically savvy
- Positive Attitude
- Organization and Multitasking
- Case Documentation
References
References available upon request.
Timeline
Sr. Case Manager
Kaiser Permanente
10.2022 - Current
Sr Case Manager
Artech LLC/Kaiser Permanente
01.2022 - 10.2022
Financial Clearance Specialist
City of Hope
01.2021 - 01.2022
Front Desk Medical Receptionist
Concentra Urgent Care
10.2019 - 03.2020
Medical Assistant
Golden Shore Medical Group
03.2016 - 01.2019
Front Desk Clerk
Molina Medical Group
06.2015 - 03.2016
Medical Assistant
My Family Medical Group
11.2011 - 06.2015
Phlebotomy -
American University Of Medical Technology
Medical Assistant -
Everest College
High School Diploma -
Don Antonio Lugo High School