Carmen Rivero Email & Phone Number | u2022 Conducts daily quality reviews of operations department processes (i.e. eligibility, enrollment, claims processing and pricing, configuration contract loads, etc.). u2022 Responds to first and second level rebuttals in a timely manner. u2022 Communicates audit results in a structured report format. u2022 Identifies and quantifies issues and recommend audit criteria to validate financial impact. u2022 Assists with special projects and other duties as assigned. u2022 Knowledge of medical terminology and/or experience with CPT and ICD-9, and HCPCS coding u2022 Ability to work in a fast paced environment with changing priorities u2022 Ability to understand and interpret contracts as related to claims processing or configuration u2022 Analyzed departmental documents for appropriate distribution and filing.u2022 Records, investigates and resolves member complaints as detailed in the Grievance Procedure Narrative u2022 Track grievance case by line of business for compliance and review u2022 Assist in resolving member and provider complaints u2022 Makes decisions that are consistent with the concept of a win-win-win for members, associates and WellCare u2022 Demonstrates based behaviors such as initiative, accountability and value. u2022 Review member's claims and identify denial reasons u2022 Effectively managing, organizing and resolving large case amounts in a timely manner u2022 Communicating with various departments in order to communally resolve cases u2022 Demonstrates appropriate customer-care skills such as empathy, active listening, courtesy, politeness, helpfulness and other skills as identified. u2022 Performs patient accounting functionality to include billing, collections, customer service, and cash applications u2022 Documents patient account activity, ensuring accuracy of patient information u2022 Responds to customer billing inquiries and posts payments to their accounts u2022 Implements billing guideline changes as prescribed by BayCare policies and procedures u2022 Identifies trends at a payer specific level and applies BayCare related policies and procedures u2022 Applies federal and state guidelines to collection efforts u2022 Interpret and follows up on Explanation of Benefits u2022 Inventories supplies, reports and tracks equipment maintenance u2022 Meet departmental metrics for quality and production on a monthly basis u2022 Acts as a subject matter expert to my peers and Management u2022 As a subject matter expert, routinely manage smaller projects to help alleviate backlog u2022 Performs other duties as assigned. u2022 Reviewed cases in order to determine whether to refer for further medical review, overturn, or uphold. u2022 Prescreened incoming cases for routing errors to facilitate their transfer to the appropriate departments. u2022 Utilized organizational skills to log, track, and process appeals according to line of business to ensure compliance. u2022 Deeply experienced in resolving provider issues by effectively communicating the details of the cases to various departments. u2022 Created and updated authorizations for services based on case review and presented results to various departments. u2022 Provided organizational leadership for appeals cases, conducting case management training, delivering new hire orientation, administering case transfer to appropriate departments, and processing of appeals.u2022 Used bilingual fluency to offer support to both Spanish and English speaking members and providers. u2022 Adhered to grievance and procedure guidelines while investigating and resolving customer complaints. u2022 Assisted in the education of new customers and in the re-education of existing customers in the proper procedures of their health plan. Handled inbound and outbound calls for Medicare as well as Medicaid. u2022 Experienced in tracking and following up on all inquiries as well as utilizing line systems and establishing procedures while simultaneously meeting all initiative accountabilities and values-based behaviors. u2022 Ensured compliance in investigating and resolving customer complaints with policies and procedures. u2022 Conducted research, compiled data, and prepared reports for presentation to the management team.u2022 Worked as Automated Logistics Specialist, supervised supply budget in order to maintain consistency. u2022 Issued military drivers licenses to qualified soldiers. Maintained vehicle histories for military police. u2022 Operated a wide range of material handling equipment, and packed supplies for shipment or storage. u2022 Initiated orders and supplies as needed; delivered/picked-up supplies and materials to locations as required. u2022 Prepared the necessary requisition supporting documents and reference materials needed for operations. u2022 Routinely conducted extensive searches for required information used in complex supply transactions. u2022 Major responsibilities included: providing supply support for personnel and managing requests and purchases for supply resources; provided timely distribution of supplies, material, and equipment. u2022 Processed supply database system transactions, updated inventory, and issued procurement procedures. u2022 Assigned responsibilities encompassed the transportation and/or distribution of supplies and equipment.

Carmen Rivero

u2022 Conducts daily quality reviews of operations department processes (i.e. eligibility, enrollmen...
Tampa, Florida, United States

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Carmen Rivero’s Email carmen.rivero@wellcare.com

Carmen Rivero’s Phone Numbers +1 813-290-****

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Carmen Rivero’s Location Tampa, Florida, United States

Carmen Rivero’s Current Industry Wellcare Health Plans

Carmen Rivero’s Prior Industry Baycare Health System | Us Army Reserves | Us Army

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Work Experience

Wellcare Health Plans

Claims Audit Specialist

2018-05-01 00:00:00 - Present

Baycare Health System

Fanancial Representative

2011-05-01 00:00:00 - 2017-05-01 00:00:00

Us Army Reserves

Automated Logistic Specialist

1999-01-01 00:00:00 - 2007-12-01 00:00:00

Us Army

Logistics Support Specialist

1999-01-01 00:00:00 - 2006-01-01 00:00:00

Skills

No Skills Available

Languages

No Languages Available

FAQ About Carmen Rivero

Carmen Rivero is located at
Tampa, Florida, United States

Carmen Rivero is a u2022 Conducts daily quality reviews of operations department processes (i.e. eligibility, enrollment, claims processing and pricing, configuration contract loads, etc.). u2022 Responds to first and second level rebuttals in a timely manner. u2022 Communicates audit results in a structured report format. u2022 Identifies and quantifies issues and recommend audit criteria to validate financial impact. u2022 Assists with special projects and other duties as assigned. u2022 Knowledge of medical terminology and/or experience with CPT and ICD-9, and HCPCS coding u2022 Ability to work in a fast paced environment with changing priorities u2022 Ability to understand and interpret contracts as related to claims processing or configuration u2022 Analyzed departmental documents for appropriate distribution and filing.u2022 Records, investigates and resolves member complaints as detailed in the Grievance Procedure Narrative u2022 Track grievance case by line of business for compliance and review u2022 Assist in resolving member and provider complaints u2022 Makes decisions that are consistent with the concept of a win-win-win for members, associates and WellCare u2022 Demonstrates based behaviors such as initiative, accountability and value. u2022 Review member's claims and identify denial reasons u2022 Effectively managing, organizing and resolving large case amounts in a timely manner u2022 Communicating with various departments in order to communally resolve cases u2022 Demonstrates appropriate customer-care skills such as empathy, active listening, courtesy, politeness, helpfulness and other skills as identified. u2022 Performs patient accounting functionality to include billing, collections, customer service, and cash applications u2022 Documents patient account activity, ensuring accuracy of patient information u2022 Responds to customer billing inquiries and posts payments to their accounts u2022 Implements billing guideline changes as prescribed by BayCare policies and procedures u2022 Identifies trends at a payer specific level and applies BayCare related policies and procedures u2022 Applies federal and state guidelines to collection efforts u2022 Interpret and follows up on Explanation of Benefits u2022 Inventories supplies, reports and tracks equipment maintenance u2022 Meet departmental metrics for quality and production on a monthly basis u2022 Acts as a subject matter expert to my peers and Management u2022 As a subject matter expert, routinely manage smaller projects to help alleviate backlog u2022 Performs other duties as assigned. u2022 Reviewed cases in order to determine whether to refer for further medical review, overturn, or uphold. u2022 Prescreened incoming cases for routing errors to facilitate their transfer to the appropriate departments. u2022 Utilized organizational skills to log, track, and process appeals according to line of business to ensure compliance. u2022 Deeply experienced in resolving provider issues by effectively communicating the details of the cases to various departments. u2022 Created and updated authorizations for services based on case review and presented results to various departments. u2022 Provided organizational leadership for appeals cases, conducting case management training, delivering new hire orientation, administering case transfer to appropriate departments, and processing of appeals.u2022 Used bilingual fluency to offer support to both Spanish and English speaking members and providers. u2022 Adhered to grievance and procedure guidelines while investigating and resolving customer complaints. u2022 Assisted in the education of new customers and in the re-education of existing customers in the proper procedures of their health plan. Handled inbound and outbound calls for Medicare as well as Medicaid. u2022 Experienced in tracking and following up on all inquiries as well as utilizing line systems and establishing procedures while simultaneously meeting all initiative accountabilities and values-based behaviors. u2022 Ensured compliance in investigating and resolving customer complaints with policies and procedures. u2022 Conducted research, compiled data, and prepared reports for presentation to the management team.u2022 Worked as Automated Logistics Specialist, supervised supply budget in order to maintain consistency. u2022 Issued military drivers licenses to qualified soldiers. Maintained vehicle histories for military police. u2022 Operated a wide range of material handling equipment, and packed supplies for shipment or storage. u2022 Initiated orders and supplies as needed; delivered/picked-up supplies and materials to locations as required. u2022 Prepared the necessary requisition supporting documents and reference materials needed for operations. u2022 Routinely conducted extensive searches for required information used in complex supply transactions. u2022 Major responsibilities included: providing supply support for personnel and managing requests and purchases for supply resources; provided timely distribution of supplies, material, and equipment. u2022 Processed supply database system transactions, updated inventory, and issued procurement procedures. u2022 Assigned responsibilities encompassed the transportation and/or distribution of supplies and equipment.