Summary
Overview
Work History
Education
Skills
Timeline
Generic

Sandra L Castellano

Pharr,TX

Summary

Dedicated and detail-oriented Customer Service professional with knowledge of service delivery and proven multitasking abilities. Committed to maintaining professional relationships to cultivate a positive image of the company and increase profitability.

Overview

17
17
years of professional experience

Work History

Quality Assurance Specialist II

Centene Corporation
03.2020 - 12.2023
  • Bi-Lingual Auditor responsible for keeping up to date on all company policies and procedures for Medicare Advantage Plans Call Center.
  • Completed 250 to 300 deviation forms monthly and recorded findings of inspection process, collaborating with quality team members and department managers to implement procedural remedies.
  • Provided regular updates to team leadership on quality metrics by communicating consistency problems.
  • Remained up-to-date and adhered to quality standards, regulations, policies to verify quality, consistency, and compliance.
  • Analyzed trends, provided recommendations for quality improvement; resolved issues and mitigated risk to confirm National Committee for Quality Assurance (NCQA) Guidelines were met.
  • Participated in calibration calls with cross-functional teams of Call Center Operations.

Customer Service Representative II

Centene Corporation
09.2018 - 03.2020
  • Bilingual Call Center Representative for high call volume environment which included inbound and outbound calls in managed care setting.
  • Managed approximately 40-60 incoming calls per day as well as high-stress situations effectively, maintaining professionalism under pressure while resolving inquiries, disputes or conflicts.
  • Provided first call resolution to member and provider inquiries by working with appropriate internal and external resources.
  • Actively listened and educated members as well as potential members on Medicare Advantage benefits in a manner that is compliant with Centers for Medicare & Medicaid Services (CMS)
  • Assisted members with website and system navigation for plan benefits and registration .
  • Maintained performance and quality standards based on established call center metrics, policies and procedures.
  • Researched and identified procedure inaccuracies in claim payments and routed to appropriate team for claim adjustment.
  • Escalated issues as appropriate through company systems for grievances and appeals.
  • Educated providers on our self-service options via company’s plan website.

Senior Case Review Processor

Molina Healthcare Of Texas
11.2014 - 11.2017
  • Bilingual Case Review Processor for inbound and outbound high call volume Call Center.
  • Initiated authorization requests for Long Term Services and Support (LTSS) for clients.
  • Data entered LTSS (Long Term Services and Support) assessments , authorizations and scheduled hours into company system.
  • Resolved member’s case issues concerning their LTSS (Long Term Services and Support) for Texas Medicaid program.
  • Cross –trained and provided back-up for other departments with Scheduling and Outbound Call Assessments.
  • Supported team members in their tasks, contributing to overall team success.
  • Increased productivity by effectively managing workload and prioritizing tasks.

PHC Clerk | Receptionist

Abundant Healthcare Services
09.2013 - 11.2014
  • Coordinated scheduling of State approved Home Health Care Provider Service hours for clients.
  • Worked closely with state funded programs to include PHC (Primary Health Care), Family Care, CAS-QMB, Texas Medicaid, CHIP, Star-Kids and Star-Plus.
  • Performed eligibility research of Home Health Services for clients.
  • Followed-up with members as well as healthcare providers as needed to make certain that member’s health needs were met.

Front Office Supervisor| Receptionist | Precertifi

South Texas Gastroenterology
02.2007 - 06.2013
  • Supervised Front Desk Receptionists
  • Conducted regular performance evaluations for front office staff to foster professional growth and development opportunities.
  • Promoted positive work environment by fostering teamwork among front office staff members.
  • Scheduled appointments for seven physicians in a high call volume office setting.
  • Balanced daily collection of co-payments received & made all daily deposits via online check system.
  • Performed research which included eligibility verification, COB, and benefits verification.
  • Initiated authorization requests for inpatient and outpatient services.
  • Requested and obtained inpatient as well as outpatient authorizations from insurances for patients’ upcoming procedures.
  • Review Physician notes for accurate billing codes and compliance.
  • Utilized Medical Terminology daily.
  • Verified insurance benefits.

Education

College Hours - Medical Transcription

South Texas College
McAllen, TX

GED -

Region One Adult Education
Pharr, TX

Skills

  • Detail Oriented
  • Quality Assurance
  • Problem-solving skills
  • Analytical Thinking
  • Customer Service
  • Team Collaboration
  • Decision-Making
  • Documentation And Reporting
  • Issue Resolution
  • Performance monitoring
  • Adaptability and Flexibility
  • Staff Mentoring
  • Word Processing

Timeline

Quality Assurance Specialist II

Centene Corporation
03.2020 - 12.2023

Customer Service Representative II

Centene Corporation
09.2018 - 03.2020

Senior Case Review Processor

Molina Healthcare Of Texas
11.2014 - 11.2017

PHC Clerk | Receptionist

Abundant Healthcare Services
09.2013 - 11.2014

Front Office Supervisor| Receptionist | Precertifi

South Texas Gastroenterology
02.2007 - 06.2013

College Hours - Medical Transcription

South Texas College

GED -

Region One Adult Education

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Sandra L Castellano