Yadira Perez
Goodyear,Az
Summary
Experienced healthcare administration professional with additional expertise in education financial advisory programs. Served in account management and corporate training roles. Proven claim and fraud investigator with excellent records management skills. Exceptionally diverse and multitalented team player who contributes to team success in any assigned duties.
Overview
22
22
years of professional experience
1
1
Certification
Work History
Provider Enrollment Specialist
Gainwell Technologies
Anchorage, AK
03.2024 - Current
- Review and update provider enrollment applications for the State of Alaska's Medicaid program to ensure accuracy and completeness of information.
- Assist providers with the completion of their application packages, including obtaining all necessary documents.
- Perform verification checks for new provider enrollments in accordance with company policies and procedures.
- Resolve discrepancies between provider applications and available data sources.
- Collaborate with internal departments to ensure proper processing of enrollment applications.
- Develop system processes to streamline the provider enrollment process and improve efficiency.
- Conduct audits of existing providers' records to verify continued eligibility for participation in network programs.
- Maintain accurate records regarding all aspects of the enrollment process in a secure database.
- Monitor daily workflow activity related to provider enrollments and identified areas for improvement.
- Process re-enrollment requests for terminated providers who wish to be reinstated into the network.
- Utilize effective active listening, interpersonal and communication skills in collaborating with different individuals on daily basis.
Clinical Administrative Coordinator/ REHIRE
OPTUM Care
Phoenix, Az
07.2022 - 02.2024
- Responsible for initial triage of members, administrative intake of Medicare members, managing the admission/discharge information post-notification, working with hospitals and the clinical team
- Handled incoming phone calls from providers and responded to inquiries accordingly.
- Monitored compliance with HIPAA regulations in regards to patient privacy rights.
- Collaborated with clinical team members regarding administration and filing for patient referrals and service authorization.
- Processed patient data documents, reports and case management files to assist clinical staff operations.
- Optimized customer health services, handling clinical admission, personnel assignments, departmental transfers and discharges.
- Managed administration of patient benefits and services according to state and federal guidelines.
- Includes managing incoming calls, managing requests for services from providers/members, providing information on available network services and transferring members as appropriate to clinical staff
- Manages the referrals process, processes incoming and outgoing referrals, and prior authorizations.
Finance Advisor
University of Phoenix
Tempe, Az
05.2019 - 04.2022
- Educated and advised students on requirements for private and Federal financial aid programs
- Utilized critical thinking and problem-solving skills to remedy student account issues
- Guided students financial aid application process and created student tuition payment accounts
- Proactively identified bottlenecks in student finance process and implemented solutions
- Communicated with/engaged other customer service departments to resolve other student issues
- Conducted self-inspections to ensure compliance with frequently changing financial guidelines
- Worked in fast-paced environment with military students overseas with limited telecom availability
- Used Spanish fluency to assist Spanish-only and Spanish-primary speaking students.
Fraud Investigator/Resolution Analyst
Optum/ United Healthcare
Phoenix, Az
01.2017 - 05.2019
- Investigated and processed fraud claims, initiated recovery and resolution actions
- Liaison to health insurance companies; gathered benefits information for commercial/gov't entities
- Ensured adherence to state and Federal compliance, reimbursement and contract policies
- Generated and maintained detailed records on policies, claims, contracts, and resolutions
- Organization/prioritization skills permitted unsupervised work even on cases involving US State Dept.
Clinical Appeals Reviewer
Optum/ United Healthcare
Phoenix, Az
12.2014 - 01.2017
- Authored processes/workflows in founding of pilot program; instrumental in implementation
- Independently reviewed and investigated claims, collaborated with MDs/RNs for data acquisition
- Analyzed records, identified trends for use in grievance filings and appeals processes
- Utilized expertise to work in the absence of established procedures and work instructions.
National Intake Coordinator
United Healthcare
Phoenix, Az
07.2010 - 12.2014
- Managed incoming provider and enrollee calls, advised on appeal process for claim denials
- Efforts merited advancement to work extensively with state and large commercial accounts
- Achieve multifaceted functionality with Medicare/retirement and commercial/state products
- Skilled in healthcare fraud prevention, fraud/waste/abuse, and escalation training programs.
Administrative Asst to Finance Manager
Jimmy Buffet's Margaritaville
Glendale, Az
01.2007 - 01.2009
- Managed hiring process including establishing employee payroll, e-verify status, and profile setup
- Served as benefits administrator, assisted in enrollment/disenrollment from benefits plans
- Entered and distributed daily sales reports and sales forecasts to corporate offices
- Delegated by general manager to develop and provide cash office training to all employees.
Claims Specialist
Biodyne Magellan Health
Phoenix, Az
01.2003 - 01.2007
- Investigate claim status, provider reimbursements, check tracing and reissuance
- Resolved ad hoc claims, made claims adjustments within established parameters
- Collaborated with MDs and PCMs in P2P reviews and appeal overrides and adjustments
- Generated/provided data on member benefits eligibility, claims, authorization status
- Subject matter expert for CMC claims, provided training/education for teammates
- Established and maintained confidential records, ensured compliance with HIPAA mandates.
Education
Commissioned Public Notary -
National Notary Association
Phoenix, AZ01.2023
B.S - Health Administration -
University of Phoenix-College of Business
A.A.S - Health Information Technology -
DeVry University
Phoenix, AzCertification - Medical Billing /Coding and Insurance -
Everest College
Peoria, Az90 RE Hours Completed - Real Estate -
Arizona School of Real Estate Business
Peoria, AZSkills
- Healthcare Administration
- Skilled Fraud Investigator
- Critical Thinking
- Analytical Skills
- Compliance
- HIPAA Laws
- Financial and Health Care Policies
- Benefit Enrollment Processes
- Documentation Management
- Telephone and email skills
- Excellent Phone Demeanor
- Physician enrollment
- Proficiency in Health Enterprise/ CMS
- Medical Terminology
- Medical Billing
- Financial Services
- UltiPro
- Bilingual (Spanish)
- Customer Service
- Medical Insurance Fraud Investigation
- Retail/Venue
- Administrative
- Multiple Database/Program Skills
- Salesforce
- Oracle
- Verint
- Genysis
- Teams / ZOOM
- Escalation Tracking (ETS)
- HSR/HSC
- ECAA
- EDSS
- IDRS
- CareOne Care Today
- CURO
- CISCO
- SEER
- EPIC
Certification
- Certified Commissioned Az State Notary
- Background Verified
- NNA Certified
- Lic Bonded.
Timeline
Provider Enrollment Specialist
Gainwell Technologies
03.2024 - Current
Clinical Administrative Coordinator/ REHIRE
OPTUM Care
07.2022 - 02.2024
Finance Advisor
University of Phoenix
05.2019 - 04.2022
Fraud Investigator/Resolution Analyst
Optum/ United Healthcare
01.2017 - 05.2019
Clinical Appeals Reviewer
Optum/ United Healthcare
12.2014 - 01.2017
National Intake Coordinator
United Healthcare
07.2010 - 12.2014
Administrative Asst to Finance Manager
Jimmy Buffet's Margaritaville
01.2007 - 01.2009
Claims Specialist
Biodyne Magellan Health
01.2003 - 01.2007
Commissioned Public Notary -
National Notary Association
B.S - Health Administration -
University of Phoenix-College of Business
A.A.S - Health Information Technology -
DeVry University
Certification - Medical Billing /Coding and Insurance -
Everest College
90 RE Hours Completed - Real Estate -
Arizona School of Real Estate Business
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