NICOLLE BARRIOS FELICIANO
Canóvanas,Puerto Rico
Summary
Dynamic Grievances and Appeals Specialist at MCS with a proven track record in compliance relations and complaint resolution. Adept in utilizing Zyter TruCare and Excel, I excel in critical thinking and decision-making, ensuring fair outcomes while enhancing member satisfaction. Committed to continuous improvement and organizational success.
Overview
2
2
Languages
5
5
years of post-secondary education
17
17
years of professional experience
Work History
Grievances and Appeals Specialist
MCS
01.2024 - Current
- Oversaw management of grievances and appeals, maintaining adherence to organizational policies and federal regulations.
- Results-driven professional who managed, investigated, and resolved member and provider grievances and appeals in compliance with federal, state, and organizational regulations.
- Specialized in compliance relations and complaint investigation, facilitating fair resolution processes for grievances and appeals.
Commercial Enrollment & Eligibility Analyst
MCS
01.2019 - 01.2024
- Coordinated and facilitated the configuration, maintenance, and ongoing implementation in the PMHS platform.
- Processed applications, gathered information, provided guidance, and determined candidates' eligibility based on established policies.
- Review quality reports of PMHS and manage comparative of electronic file of existing clients in the system for maintenance changes.
Claims Clerk
MCS
01.2017 - 01.2019
- Manages day-to-day claims operations, including claims evaluation, adjudication and customer service in accordance with agreed quality and production standards.
- Processes claims in a timely manner and complies with industry fair claims practices and applicable state regulations concerning the processing of claims.
- Processed claims promptly while ensuring compliance with industry fair claims practices and state regulations.
- Managed team of claims professionals, including care coordination and intake nurses, claims examiners, benefit/customer service specialists, and administrative support personnel; conducted regular performance evaluations.
- Cultivated professional relationships with superiors to enhance communication and collaboration.
Customer Service and Attendant
Puerto Rico Convention Center
06.2015 - 01.2017
- We combine our skills as a team to satisfy our clients' wishes.
- Prioritized quality and client satisfaction in all service interactions.
- Managed event setup and breakdown for various functions at the convention center.
- Assisted guests with inquiries and provided information on services offered.
- Coordinated logistics for vendors and exhibitors during events and conferences.
MRI Clinical Rotation
Insight Radiology
01.2015 - 01.2016
- Prepare and position patients to produce high-quality images, perform imaging exams, and collaborate to establish protocols for obtaining the highest diagnostic image quality.
- Administered contrast media to patients during imaging procedures.
- Adhere to all regulatory and safety standards, educate patients on procedures, and answer patients' questions.
CT Scan Clinical Rotation
Centro Médico de Puerto Rico (ASEM)
01.2015 - 12.2015
- Performed quality diagnostic CT Scan examination.
- Positioned and immobilized patients on examining table, using supportive device to obtain precise patients' positions and followed protocols specified by radiologist.
- Administered contrast media and monitored patients to ensure safety and effectiveness during diagnostic procedures.
Conventional Radiology Clinical Rotation
Corporación del Fondo del Seguro del Estado
01.2014 - 12.2014
- Capture Images of organs and tissues for diagnosis purposes.
- Using equipment, positioning patients, making sure unnecessary exposure is avoided and performing administrative tasks.
- Completed day-to-day duties accurately and efficiently.
- Contributed innovative ideas and solutions to enhance team performance and outcomes.
- Worked successfully with diverse group of coworkers to accomplish goals and address issues related to our products and services.
Administrative Assistant
AXDA
01.2013 - 01.2014
- Achieved significant project milestones during employment.
- Led a diverse team to enhance collaboration.
- The goals of my team were my professional satisfaction at that moment.
- I also had administrative tasks to complete.
Conventional Radiology Clinical Rotation
Hospital del Maestro
01.2012 - 01.2013
- Captured images of organs and tissues for diagnostic purposes using advanced imaging equipment. of organs and tissues for diagnosis purposes.
- Using equipment, positioning patients, making sure unnecessary exposure is avoided and performing administrative tasks.
- Completed day-to-day duties accurately and efficiently.
- Contributed innovative ideas and solutions to enhance team performance and outcomes.
- Worked successfully with diverse group of coworkers to accomplish goals and address issues related to our products and services.
Customer Service and Sales Representative
Silver Collection
01.2010 - 01.2013
- Worked under pressure and independently to manage customer inquiries.
- Described positive experiences during work.
- Put into practice use of technology and computer skills.
- Also, I got to interact with clients who came concerns and helped them solve their poor satisfaction with the company.
Conventional Radiology Clinical Rotation
Corporación del Fondo del Seguro del Estado
01.2011 - 01.2012
- Capture Images of organs and tissues for diagnosis purposes.
- Operated medical imaging equipment to capture diagnostic images., positioning patients, making sure unnecessary exposure is avoided and performing administrative tasks.
- Completed day-to-day duties accurately and efficiently.
- Contributed innovative ideas and solutions to enhance team performance and outcomes.
- Worked successfully with diverse group of coworkers to accomplish goals and address issues related to our products and services.
Education
Master 's Degree - Industrial and Organizational Psychology, PhD
Albizu University
San Juan, P.R. 01.2022 - 12.2026
Medical Billing and Coding Certification -
University of Puerto Rico
Rio Piedras, P.R.Privacy and Security HIPAA Certification -
MCS Healthcare Holdings
San Juan, P.R.Fraud, Abuse and Waste Certification -
MCS Healthcare Holdings
San Juan, P.R.Phishing and Malware Certification -
MCS Healthcare Holdings
San Juan, P.R.Master's Degree - Health Services Administration and Health Service Management, MHSA
Ana G. Méndez University
Carolina, P.R.Bachelor's Degree - Radiologic Science with Major in CT and MRI
Universidad Ana G. Méndez
Carolina, P.R.Skills
- Case Management
- PMHS
- Data Analysis
- Excel
- PowerBI
- Access
- Visio
- Diagramming software
- Critical thinking
- Decision making
- Planning
- Detail Oriented
- Adaptability
- Flexible
- Initiative
- Adaptability
Languages
Spanish
First Language
English
Advanced (C1)
C1
Timeline
Grievances and Appeals Specialist
MCS
01.2024 - Current
Master 's Degree - Industrial and Organizational Psychology, PhD
Albizu University
01.2022 - 12.2026
Commercial Enrollment & Eligibility Analyst
MCS
01.2019 - 01.2024
Claims Clerk
MCS
01.2017 - 01.2019
Customer Service and Attendant
Puerto Rico Convention Center
06.2015 - 01.2017
MRI Clinical Rotation
Insight Radiology
01.2015 - 01.2016
CT Scan Clinical Rotation
Centro Médico de Puerto Rico (ASEM)
01.2015 - 12.2015
Conventional Radiology Clinical Rotation
Corporación del Fondo del Seguro del Estado
01.2014 - 12.2014
Administrative Assistant
AXDA
01.2013 - 01.2014
Conventional Radiology Clinical Rotation
Hospital del Maestro
01.2012 - 01.2013
Conventional Radiology Clinical Rotation
Corporación del Fondo del Seguro del Estado
01.2011 - 01.2012
Customer Service and Sales Representative
Silver Collection
01.2010 - 01.2013
Medical Billing and Coding Certification -
University of Puerto Rico
Privacy and Security HIPAA Certification -
MCS Healthcare Holdings
Fraud, Abuse and Waste Certification -
MCS Healthcare Holdings
Phishing and Malware Certification -
MCS Healthcare Holdings
Master's Degree - Health Services Administration and Health Service Management, MHSA
Ana G. Méndez University
Bachelor's Degree - Radiologic Science with Major in CT and MRI
Universidad Ana G. Méndez