Reina Liliana Carrion

• Handle employee benefits inquiries and resolve employee insurance issues, including managing the benefits’ general inbox.
• Formulate solutions to solve needs regarding benefits
• Assists employees regarding benefits claim issues and plan changes. Conduct review, research, and troubleshoots to resolve benefits-related issues and update management and employees.
• Support the Benefits Manager and liaises with the benefits carriers, serve as a point of contact for vendors and third-party administrators to file claims and ensure to provide accurate eligibility information.
• Processes and administers leave-of-absence requests and disability paperwork: medical, personal, disability, and FMLA.
• Work directly with supervisor on return-to-work programs, FMLA, and Non-Industrial leave.
• Help ensure benefit plans are administered according to plan provisions and the company’s regulatory guidelines.

• Review, research and determine referral appropriateness based on health plan or medical group criteria. P
• Coordinate patient information between Case Managers and Skilled Nursing facilities
• Serve as a resource to additional Care Coordinators & Customer Service Departments for all referral inquiries
• Perform Health Plan benefit and eligibility inquiries
• Review cases with Medical Directors with attached Health Plan criteria and appropriate medical records
• Research, review and data entry of commercial and retrospective claims.
• Used company software and databases to maintain records of services performed and patient conditions.

• Responsible to trouble shoot referrals and claim related issues
• Obtained and analyzed members’ detailed benefit coverage
• Gathered patients’ information including health plan criteria to support nurse’s decision making process on prior authorizations.
• Made benefits determinations on referrals based on authorization level
• Utilized
• HCPC, ICD-9 and CPT-4 coding books to determine medical appropriateness for procedure and diagnosis.
• Responsible for analysis, and data entry of all electronic and hardcopy referrals for assigned region.
• Completed paperwork, recognizing discrepancies and promptly addressing for resolution.
• Used strong analytical and problem-solving skills to develop effective solutions for challenging situations.
• Worked effectively in fast-paced environments.
• Worked well in team setting, providing support and guidance.

• Accountable for all pending claims received for utilization review from claims processing department
• Completed extensive research including verification of provider information, ICD-9, CPT-4, HCPC coding, and dates of service
• Cross-referenced claims for authorization as well as regulatory Policy and Guideline Procedures
• Processed claims of various service types such as; office visits, emergencies, ambulance transport, durable medical equipment (DME), home health and inpatient/outpatient procedures.
• Resolved problems, improved operations and provided exceptional service.
• Adaptable and proficient in learning new concepts quickly and efficiently.
• Paid attention to detail while completing assignments.

• Responsibilities for interpreting ICD-9, HCPC and CPT-4 coding of all incoming referrals, inpatient/outpatient admissions, durable medical equipment (DME) requests, and identifying prior authorizations and notifications.
• In addition, entered referrals and confirmed member’s eligibility.
• Worked closely with concurrent review nurse, and ensured bed days were entered accurately while patient’s information was completed promptly.
• Followed up with medical staff regarding missing information in patient records.
• Utilized electronic medical record systems to store, retrieve and process patient data.