Xiomara Rosas-Montalvo
Kissimmee,FL
Summary
Highly trained as Risk Management with strong clinical abilities and a successful career in both pharmaceutical drugs and medical billing/Account Receivable. Proactive and organized with passionate commitment to first-rate patient care. Talented Case Manager adept at handling high caseloads without sacrificing quality of care. Operates in high-pressure environments while recommending best resources and courses of action to benefit patient needs and return each to optimal quality of life.
Overview
16
16
years of professional experience
Work History
Case Management Social Worker
ApprioHealth Inc
12.2019 - 06.2024
- Interviewed potential clients to confirm eligibility and completed psychosocial assessments.
- Interpreted and explained treatment and benefit programs to clients.
- Provided crisis intervention services when required, deescalating situations and connecting clients with appropriate supports to ensure their safety.
- Facilitated successful client transitions from hospitalization to community-based care through coordinated discharge planning.
Medicaid/Financial Consultant
Financial Healthcare Resources
10.2018 - 12.2019
- Pre-screen patient face to face or over the phone for potential Medicaid Eligibility, private or commercial insurance
- Knowledge of Medicare A& B Coverage
- Submit disability and/or Medicaid application online
- Assist individuals through registration process for Medicaid services
- Prepare packets with verifications to obtain approvals in timely manner
- Ability to obtain 3rd party documents to assist client and or families
- Evaluate and monitor the process until benefits are approved
- Effectively manage Medicaid case load, efficiently educate individual and families about available Medicaid services and support
- Working with Social Security Administration to obtain proof of income and complete representative payee forms
- Fax all proper documents to agencies such as Cares, Senior Resource Alliance and DCF for the approvals of the level of care critical in the Medicaid approval
- Ensure facility receives patient responsibility determined by DCF
- Follow up, update client on a weekly basic.
Plan Sponsor Consultant
Aetna
02.2018 - 06.2018
- Successfully review each medically billed order for proper medical benefits verification
- Conduct benefits investigations for varies of commercial, private, Medicare, Medicaid and more
- Knowledge of federal and government programs
- Work on all rejections orders by entering appropriate administrative overrides
- Resolve all secondary electronic payer rejections and add proper copay (CPA) program to get a paid claim
- Ensure all confirmed mail orders are successfully processed and shipped according to confirmed delivery date
- Complete all prior authorization forms via fax or over the phone by having full understanding of HCPCS, CPT, ICD-9 and ICD-10.
Patient Advocate
Prime Therapeutic Pharmacy
08.2013 - 10.2017
- Work to prioritize and resolve order issues including working with shipping vendors/third party logistics to track lost or undelivered merchandise return
- Provide a timely response internal/external customer order inquiry by telephone and/or email in an in or outbound services center, consistent with service and quality standards
- Assist on special projects such VIP process, Error reporting and rescue reporting, auditing reporting of patient coordinator including AUX report and order audits.
Lead Case Management Program
KePro
07.2011 - 08.2013
- Made many /outbound calls to patient by educating them to engaging into case management program
- Enroll patients into case managements and benefits.
Patient Service Specialist
CuraScript/ Client Services
03.2008 - 02.2011
- Made inbound/outbound calls answering pharmacy related benefits questions for members, providers
- Work on resolving any escalated issues by reaching out to client.
Education
Diploma - Medical
U.S. Career Institute
08.2007
Diploma -
Cypress Creek High School
05.1998
Skills
- Data Entry
- Sales
- Outlook
- Homelessness Prevention
- Behavioral Health Knowledge
- Assessment skills
- Disability Support
Personal Information
Title: Case Management
Languages
Spanish
Full Professional
Timeline
Case Management Social Worker
ApprioHealth Inc
12.2019 - 06.2024
Medicaid/Financial Consultant
Financial Healthcare Resources
10.2018 - 12.2019
Plan Sponsor Consultant
Aetna
02.2018 - 06.2018
Patient Advocate
Prime Therapeutic Pharmacy
08.2013 - 10.2017
Lead Case Management Program
KePro
07.2011 - 08.2013
Patient Service Specialist
CuraScript/ Client Services
03.2008 - 02.2011
Diploma - Medical
U.S. Career Institute
Diploma -
Cypress Creek High School
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