FABIOLA M. RIOS CRUZ
Trujillo Alto
Summary
Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.
Overview
6
6
years of professional experience
Work History
Grievances & Appeals Specialist
TRIPLE S SALUD
11.2023 - Current
- Receives complaints and appeals filed by enrollees, providers and regulatory agencies, register them in the system and in different 'logs' that are required in the department
- Makes calls to enrollees, providers, and staff to validate their complaints and appeals allegations to channel them correctly, according to the regulations
- Correctly classify the cases according to regulations
- Creates case file with the enrollee's eligibility information according to HEALTH SUITE/Qnex including but not limited to contract information, address, eligibility date and any other information relevant to the investigation, including interventions with the delegated entities
- Also, includes in the file information of the service, claim, provider, etc
- Related to the case
- Prepares the grievances and appeals acknowledgement letter
- Assigns cases to the A&G Analysts and/or A&G Coordinators
- Assist them in the investigation process by gathering the necessary information through the systems or by calling the enrollees and/or providers as necessary
- Audits case files of closed complaints and appeals, reports the findings and archive the case files
- Prepares daily, weekly and monthly Appeals and Grievances Reports as required by regulatory agencies and/or the Unit's Management
- Receives calls from enrollees and providers and canalize them accordingly
- Coordinates training, meetings, visits, calls, send faxes and correspondence and prepare materials requisition for the Appeals and Grievances Unit
- Receives and distribute daily mail and fax
- Assists with maintaining regulatory compliance, timeliness requirements and ensuring accuracy standards are met
- Completes day-to-day operational tasks assigned according to defined processes and procedures
- Assists with tracking and maintaining case records
- Assists with collecting and reporting data
- Complies and is consistent with the standards, policies, and procedures of the Company, together with local and federal laws applicable to our industry, business and employment practices compliant.
Member Engagement Representative
TRIPLE S SALUD
05.2021 - 11.2023
- Helped large volume of customers every day with positive attitude and focus on customer satisfaction
- Documented and detailed calls and complaints using call center's CRM database
- Adhered to company policies and scripts to consistently achieve call-time and quality standards
- Responded to customer calls and emails to answer questions about products and services
- Placed outbound customer service or customer satisfaction calls to follow up on issues
- Maintained and managed customer files and databases
- Escalated complicated customer account issues to supervisors and help desk workers
- Resolved concerns with products or services to help with retention and drive sales
- Learned and maintained in-depth understanding of product and service information to offer knowledgeable and educated responses to diverse customer questions
- Make changes of coverage under the Medicare Advantage line in the Annual Membership, Period (AEP), Open Period (OEP) and special periods (SEP and Dual-Reform).
Medical Assistant
Institute of Cardiology
05.2018 - 01.2021
- Sanitized, restocked, and organized exam rooms and medical equipment
- Directed patients to exam rooms, fielded questions, and prepared for physician examinations
- Obtained client medical history, medication information, symptoms, and allergies
- Performed medical records management, including filing, organizing and scanning documents
- Collected and documented patient medical information such as blood pressure and weight
- Called and faxed pharmacies to submit prescriptions and refills
- Documented vital signs and health history for patients in clinic and hospital environments
- Scheduled appointments, registered patients, and distributed sample pharmaceuticals as prescribed
- Completed clinical procedures and gathered patient data for interpretation by physician
- Verified patient insurance coverage and collected required co-payments
- Completed EKGs and other tests based on patient presentation in office.
Education
Bachelor of Science in Diagnostic Sonography -
Ana G Mendez University
Carolina, PR05.2018
Skills
- Transcription (3 years)
- CRM Software (2 years)
- Medical Records (3 years)
- Customer service (5 years)
- Clerical Experience (3 years)
- Computer skills
- Communication skills
- Medical terminology
- Office experience
- Medical office experience
- Professionalism and Ethics
- Microsoft Office
Additional Information - Reference
Available
Timeline
Grievances & Appeals Specialist
TRIPLE S SALUD
11.2023 - Current
Member Engagement Representative
TRIPLE S SALUD
05.2021 - 11.2023
Medical Assistant
Institute of Cardiology
05.2018 - 01.2021
Bachelor of Science in Diagnostic Sonography -
Ana G Mendez University
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