Roxann Heston-Rojas
Carmichael,CA
Summary
Highly-motivated employee with desire to take on new challenges. Strong worth ethic, adaptability and exceptional interpersonal skills. Adept at working effectively unsupervised and quickly mastering new skills.
Overview
18
18
years of professional experience
Work History
Program Coordinator
Centene
Rancho Cordova, CA
03.2023 - Current
- Processed requests for Case Management referrals.
- Conducted telephonic outreach to members to explain and offer Case Management services
- Conducted Health Risk Assessments.
- Requested Medical Records from hospitals in a timely manner as requested by Case Managers.
- Worked closely with Case Managers to ensure all required documents were received for timely review.
- Performed other administrative duties as requested.
UM Coordinator
Dignity Health
Rancho Cordova, CA
03.2022 - 03.2023
- Coordinated the inpatient out of area process including creation, formation and data entry.
- Requested clinical information from hospitals in a timely manner.
- Worked closely with the out of network nurse(s) to ensure all required documents are received for timely review.
- Performed other administrative duties as requested.
Autism Services Coordinator
Health Net Federal Service
Rancho Cordova, CA
12.2015 - 03.2022
- Processed authorizations received for services in accordance with contractual standards.
- Completed provider selection in compliance with 28-day access to care standards.
- Gathered all relevant information by contacting appropriate physicians or other ancillary providers and utilized this information to authorize services as requested.
- Documented case summary based on information received and communicated with the beneficiaries and involved providers.
- Referred cases to the clinical reviewers or the Department Manager when appropriate.
- Assisted the clinical review staff in the collection and data entry of treatment plans.
- Educated beneficiaries and their families to help them understand their benefits and assisted them in maximizing their available benefits.
Medical Management Lead
BRMS
Folsom, CA
05.2014 - 10.2015
- Certified low level requests using evidence based guidelines.
- Quality Assurance of work entered by coordinators.
- Trained and offered support for all department new hires.
- Reviewed weekly reports.
- Department lead - Assisted with escalated calls, concerns, issues and policies.
- Updated employees on new regulations, procedures and updates.
- Supported the Medical Case Manager with the intake, completion and work of all outgoing letters and documents.
- Authorized medical services by using medical policy guidelines.
- Entered all Utilization Review data in the Medical Utilization Review system.
- Reviewed all medical reports to identify treatment requests.
- Followed written criteria, policies and procedures in reviewing and processed daily referrals for outpatient and inpatient medical care.
Bed Control Coordinator
CHOC Children's Hospital
Orange, CA
05.2006 - 12.2013
- Assisted Admit Nurse and House supervisor in recording admission requests to the hospital
- Coordinated the placement of all inpatients (urgent, emergent and elective) between referring physicians, hospital personnel and nursing staff.
- Verified insurance and entered all financial, demographic and emergerncy information into admitting systems.
- Assisted with admitting interviews and paperwork as requested.
Education
High School Diploma -
San Gabriel Mission High School
San Gabriel, CA06-1995
Skills
- Program follow-up and assessment
- Ongoing client support
- Referral Coordination
- Report creation
- Training Coordination
- Patient prioritization
- Healthcare regulations
- Policy Adherence
- Critical Thinking
- Decision-Making
- Problem-solving abilities
- Time Management
- Teamwork and Collaboration
Timeline
Program Coordinator
Centene
03.2023 - Current
UM Coordinator
Dignity Health
03.2022 - 03.2023
Autism Services Coordinator
Health Net Federal Service
12.2015 - 03.2022
Medical Management Lead
BRMS
05.2014 - 10.2015
Bed Control Coordinator
CHOC Children's Hospital
05.2006 - 12.2013
High School Diploma -
San Gabriel Mission High School
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