SEANETT TORRES ESPINOZA

Eligibility & Enrollment, Billing Account Rep. Etc

Aetna

11.2006 - 12.2020

Performed enrollment data entra by inputting employees demographic and plan selections. Made updates during open enrollment period plan change request for new enrollments and renewals.
Verified Census data for accurate group enrollment such as; family, individual, employee & child etc.
Worked aged reports.
Assisted clients with accurate eligibility form, application and document completion.
Followed guidelines when reviewing applicant data to determine eligibility for economic assistance.
Scheduled appointments with applicants to gather information and explain benefits processes
Collaborated with department managers (account managers etc.)to correct problems and improve services, improving efficiency and customer service ratings 100%.
Assist on occasion with developments of such Resources, Monitors and Manages internal installation process, reports to identify issues timely and accurate resolution to meet business goals and constituents expectations.
Ensured that Legislations and compliance has been properly adhered to regarding Plan Sponsor and/or Member activity.
Handled heavy call volume each day.
Ran rates for accuracy with contract agreement and uploaded missing rates.
Analyzed monthly account receivable and payable reports to facilitate timely filing, third-party payments and consistent cash flow.
Stayed calm under pressure to allow for difficult situation to be handled in a professional and successful manner in instances of deadlines etc.
.
Followed state legislature protocols according to safeguard of confidentiality of patient records and maintained HIPPA guidelines.
Performed job functions via Rumba, CCI, Strategic Contract management, Excel programs, Microsoft systems and ASD systems etc.
Addressed bad debts for plan sponsors and individual plans negative balances that were in line with set protocols by setting up payment arrangements to prevent accounts from going into collections.
Multiple job functions such as, post payments, set up payment arrangements, research billing information to ensure invoice was billed properly, developed invoices for issuance, ran rates for missing rates, demographic update and input and update incorrect information.
Verified coding information was implemented correctly, set accounts for refunds processing, properly notated accounts in detail etc
Processed payments using cash, check and credit cards, maintaining accurate records of transactions
Set accounts up for Refunds when warranted
Issued receipt and payment agreement documentation.
Set patients accounts up for financial assistance review.
Review accounts and set up invoices accounts to insure proper coding and billing to be corrected.
Verified insurance coverage was properly applied in accordance to services rendered.
Assisted Attorney office with provision of medical and billing records etc.
Served as the first point of contact for handling a high volume of inbound and outbound telephone calls to resolve patient/guarantor billing concerns and inquiries from patients, guarantors, and others such as insurance companies, attorney offices, or other healthcare providers for both hospital and professional billing settings
Educated Plan sponsors and members education concerned and billing processing.
Experience well versed in HB, PB Customer Service working competency in all areas of the SBO
Integrate customer service and self-pay collection activities across Medical Center Facilities and Physician claims.
Update Physician Networks information that coincided with the groups locations, provided a single point of contact for assigned groups. developed single billing statements and increased transparency to guarantors, thereby improving the patient collection process and patient experience.
Process refund payment request., Responded to Employers and Account managers requests, offering excellent support and tailored recommendations to address needs of each individual plan sponsor.
Processed and certified documents for accuracy and compliance with government regulations.
Assisted clients with eligibility form, guidelines application and document completion.
Resolved discrepancies with client applications to verify eligibility set backs.
Investigated and resolved member and plan sponsor inquiries and complaints timely manner.
Collaborated with sales, Broker and Plan Sponsors members to stay current and resolve item issues.
Performed functions in Salesforce system
Performed Data Entry functions.
Appeals Review and submissions.
Assisted the Complaints and Appeals Dept with multiple projects.
Review and Update accounts with correct plan information.
Educated both plan sponsors and members about billing, payment processing and support policies and procedures.
Sought ways to improve processes and services provided
Collaborated with staff members to enhance customer service experience and exceed team goals through effective client satisfaction rates
Optimized customer support by establishing collaborative service environments through targeted operational initiatives
Followed up with customers about resolved eligibility and claim issues.
Assist Brokers and Group representatives with group control updates and correct Eligibility decrespencies and Claims processing updates etc.
Respond to Member and Plan Sponsor inquiries via phone, internet and written correspondence.
Inquires are basic and routine in nature and Triage resulting rework to appropriate staff
Document and followup with member and plan sponsor concerns and request in relations to account status etc.
Assist Account Managers with varieties of issues in updating enrollments changes and updates.
Explain member's rights and responsibilities in accordance with contract guidelines.
Process and verify claim information and verification of referrals requirement HMO, EPO plans services needed for new claim handoffs to nurses for review and medical director in solving appeals and complaints cases.
Write up and submit complaints and appeals
Issue correspondence letters via the utilization of the target systems.
Once plans are updated or corrected new ID cards were issued via DMD system, Rumba or ASD system
Educate Clients on procedures and process
Services preformed in call center environment
Managed high call volume from both inbound and outbound calls per day.
Resolved discrepancies with client employees enrollment found via the employees applications submitted for processing of eligibility and enrollment.
Communicated with people from various cultures and backgrounds on application process.
Devised and implemented strategies to streamline eligibility verification processes.
Developed extensive fact-checking and research skills by continuously reviewing different submitted enrollment information.
Facilitated information and resource exchanges with external agencies to progress client applications.
Established databases to track, analyze and automatic eligibility application processes.
Assisted with training new representatives on current eligibility requirements and policies.
Maintained Assigned and Managed multiple accounts
I identified, researched, and resolved billing variances to maintain system accuracy and currency
Assisted with billing inquiries and provided timely responses to enhance customer satisfaction
Collaborated with department managers to correct problems and improve services, improving efficiency and customer service ratings 100%
Prepared journal entries to post to general ledger
Prepared and submitted monthly billing reports to management for financial overview
Contacted clients with past due accounts to formulate payment plans and discuss restructuring of payment when Employer previously overpay
Provided excellent customer service, developing and maintaining client relationships
Worked with multiple departments to check proper billing information
Prepared itemized statements and bills and invoices, recording amounts due for purchases or services rendered
Monitored customer accounts to identify and rectify billing issues
Communicated with clients to review and verify client billing requirements
Generated invoices upon receipt of billing information and tracked collection progress
Generated and submitted invoices based upon established accounts receivable schedules and terms
Processed and verified invoices to secure accuracy of billing information
Researched and resolved billing discrepancies to enable accurate billing
Identified payment trends and adjusted billing processes accordingly to retain customers
Developed and maintained billing procedures to make timely payments
Analyzed monthly account receivable and payable reports to facilitate timely filing, third-party payments and consistent cash flow
Posted data and kept other records concerning costs of plans signed up for
Reviewed and reconciled customer accounts to manage accuracy of payments received
Generated monthly invoices for customers (Employers) in multiple formats to provide transparency
Consult with internal/external customers to identify accurate account structure, billing format method and payment arrangements to meet customer expectations
May negotiate and communicate changes for non-standard products and/or services; evaluations customer billing requirements, customer payment arrangements and history to deliver a timely and technically issues, form internal and external customers
Research, resolves and responds to product inquires, revenue adjustments via Plan sponsor, Member services, third party vendors
Utilize and interpret online resources to understand customer account structure and benefits
I identified, researched, and resolved billing variances to maintain system accuracy and currency
Assisted with billing inquiries and provided timely responses to enhance customer satisfaction.
Maintained Assigned and Managed multiple accounts.
Resolved discrepancies with client applications to verify eligibility.
Exhibited high energy and professionalism when dealing with clients and staff
Handled customer inquiries and suggestions courteously and professionally
Clarified customer issues and determined root cause of problems to resolve or service complaints
Utilized customer service software to manage interactions and track customer satisfaction
Assisted with training new personnel regarding company operations, policies and services
Optimized customer support by establishing collaborative service environments through targeted operational initiatives
Bolstered customer retention by creating and offering unique discount options and inspiring interest in new product lines according the member plan
Actively listened to customers, handled concerns quickly and escalated major issues to supervisor
Developed and updated databases to handle customer data
Educated customers about billing, payment processing and support policies and procedures
Tracked customer service cases and updated service software with customer information
Answered constant flow of customer calls with minimal wait times
Increased efficiency and team productivity by promoting operational best practices
Sought ways to improve processes and services provided
Updated account information to maintain customer records
Offered advice and assistance to customers, paying attention to special needs or wants
Liaised with sales, marketing, and management teams to develop solutions and accomplish shared objectives
Answer question and resolve issues based on phone calls/ letters from members, providers, and plan sponsors
Triages resulting rework to appropriate staff
( Handle extensive file review requests)
Document and follow up with Members concerns via service request pertaining to plan and claim status
Explain Members rights and responsibilities in accordance with contract guidelines
Process and verify claim referrals/implement referrals in the system once verified via Primary Care
Provider
New claim handoffs, Nurse reviews, Complaints, grievance and appeals via target system
Educate Members on company self-service options via Aetna online system "Navigator" website
Prepare and submit Complaints and Appeals
Assist in determination of Medical Necessity , Applicable coverage provisions and verify member plan eligibility relating to incoming correspondence and internet referrals
Perform reviews of members claim history to ensure accurate tracking of plan benefits maximums, coinsurance and deductible
Assist with Retirement benefits updates and eligibility
Additional duties to include; Perform Financial data maintenance as necessary and processing of payments
Provided billing information via Billing systems
Use applicable systems tools and resources to produce quality letters and spreadsheets in responses to inquiries received
Advise of plans offered in relations to Aetna Individual plans options
Also, enrolled in plan choices
Advised members of Provider Participation and issued provider listing
Priced Procedure codes according to provider of service contract agreement
Experience with Government/ Market Place accounts and issued plans such as via Obama Care
(signed members up in individual plans and collected premium payments, advised of detailed plan coverage information.)
Handled Medicare calls by reviewing providing claims and benefits
Appeals review etc
Handled Pharmacy pricing and claims review etc

Summary

Overview

Work History

Customer Service Self Pay Specialist I

Financial Representative

Eligibility & Enrollment, Billing Account Rep. Etc

Education

Bachelor - Business Administration And Management

Associate of Science - Business Administration

Skills

Timeline

Customer Service Self Pay Specialist I

Financial Representative

Eligibility & Enrollment, Billing Account Rep. Etc

Bachelor - Business Administration And Management

Associate of Science - Business Administration

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