Gillian Sepúlveda Moreno
Bayamón
Summary
Proven Claims Specialist with a track record at Caridad Headquarters & Distribution Center, adept in claims processing and demonstrating exceptional time management skills. Excelled in resolving complex claims and enhancing customer service through meticulous documentation review and effective communication. Achieved significant improvements in claims resolution efficiency without compromising accuracy or compliance.
Overview
12
12
years of professional experience
1
1
Certification
Work History
Claims Specialist and Payment Audit
Caridad Headquarters & Distribution Center
06.2022 - Current
- Managed a high volume of claims effectively by prioritizing tasks and maintaining excellent organizational skills.
- I develop strong working relationships with external partners, such as adjusters, to facilitate efficient claims resolution processes.
- I resolve complex claims fairly by applying critical thinking, negotiation skills, and detailed knowledge of PBM policies.
- Analyzed claim documents to ensure accuracy and compliance, mitigating risk of financial loss.
- I collect, review and validate supporting documentation for appeals.
- I classify and order the case in the system according to the determination made by the medical plan
- Ensured accurate data entry based on research
- Shared and sent reports on case status, resolution times, and appeal conclusion
- Planned, prioritized and organized the work to be completed to meet established and required deadlines.
Buyer's Assistant
RxWarehouse Caridad
01.2021 - 03.2022
- Maintained complete documentation and records of all purchasing activities.
- Processed purchase orders and invoices in accordance with company procedures.
- Reviewed purchasing trends and forecast demand for inventory planning and replenishment.
- Utilized software to order, track and invoice product shipments.
- Implemented policies and procedures for optimal purchasing methods and cost control.
- Excellent communication skills, both verbal and written.
- Assisted with day-to-day operations, working efficiently and productively with all team members.
- Demonstrated strong organizational and time management skills while managing multiple projects.
Pharmacy Team Leader
Farmacia Caridad #4
09.2018 - 01.2021
- Conducted regular audits of controlled substances inventory levels, ensuring compliance with state and federal regulations.
- Organized the schedules of the technicians and graduates for the company's shifts
- Coordinated the tasks
- Mentored new team members for seamless integration into the pharmacy team and accelerated learning curve.
- Resolved complex insurance issues, working diligently with insurers to ensure timely coverage approvals for patients'' medications.
- Reduced medication errors through diligent attention to detail and strict adherence to protocols.
- Developed strong relationships with patients, fostering trust and loyalty to the pharmacy.
- Implemented effective marketing strategies to attract new customers while retaining existing clientele base.
- Assisted other pharmacy staff with drug inventory, purchasing and receiving.
- Managed drug and supply inventories.
- Monitored ordering of pharmacy medication stock to maintain streamlined inventory and low overhead.
Pharmacy Technician
Farmacia Caridad
10.2012 - 09.2018
- Answered incoming phone calls and addressed questions from customers and healthcare providers.
- Analysis and interpretation of medical prescriptions.
- Bill prescriptions in the RX30 system.
- Stocked, labeled, and inventoried medication to keep accurate records.
- Enhanced pharmacy workflow by assisting pharmacists with medication dispensing, labeling, and packaging.
- Calculated dosage, filled prescriptions, and prepared prescription labels with absolute accuracy.
- Promoted patient confidentiality by adhering to HIPAA regulations when handling personal information during transactions.
- Assisted in maintaining a clean and organized work environment, ensuring compliance with safety regulations.
- Assisted in training new team members on standard operating procedures to ensure consistent quality of service across the entire team.
- Assisted pharmacists in preparing and dispensing medications to ensure patient safety.
Education
Associate of Science - Pharmacy Technician
Centro De Estudios Multidisciplinarios
Bayamón, Puerto Rico04-2013
High School Diploma -
Colegio Dra. Wilma Chavez
Trujillo Alto, Puerto Rico06-2009
Skills
- Claims processing
- Analyst
- Billing
- Time management
- Customer service
- Claims investigation
- Documentation review
- Verbal communication
- Microsoft office
- Excel
- Attention to detail
- Daily reporting
- Claims analysis
- Prescription verification
Certification
- [PR] Driver's License
Timeline
Claims Specialist and Payment Audit
Caridad Headquarters & Distribution Center
06.2022 - Current
Buyer's Assistant
RxWarehouse Caridad
01.2021 - 03.2022
Pharmacy Team Leader
Farmacia Caridad #4
09.2018 - 01.2021
Pharmacy Technician
Farmacia Caridad
10.2012 - 09.2018
- [PR] Driver's License
Associate of Science - Pharmacy Technician
Centro De Estudios Multidisciplinarios
High School Diploma -
Colegio Dra. Wilma Chavez
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