Published on: Mar 3, 2016
Transcripts - Natalie Casales-Resume
Miami, FL 33175
Highly proficient in the use of
Excellent verbal and written
communication skills in
Expert knowledge with computer
programs: MicrosoftWord, Excel,
Outlook,QNXT,CCA, UMK2, Interqual.
Punctual, fast learner and work well
Provenability to identify, analyze and
solve problems effectively despite
sudden deadlines and changing
Comfortable working withAged,
Blind, Disabled, and Severely Mentally
Ill populations with varied economic
and educational circumstances.
Excellent leadership and training
Able and willing to assist co-workers,
supervisors and clients in a
Understands the importance of
working withtime sensitive material.
Strong background with system
automation of Case management
processes and workflows.
Strong skills in time management,
prioritizing, and meeting deadlines.
Understand the importance of
Maintain member respect and dignity
while displaying maturity, empathy,
ethics, confidentiality and
Molina Health Care Case Management Processor Transitions of Care
Conducts follow up telephone calls withmembers after hospital discharge for coordination.
Conduct any additional calls needed to facilitate transition of care.
Arrange for health care services within the scope of available benefits.
Maintains active caseload and conductfollow-upcalls.
Maintain department quality standards.
Discuss the importance of understanding prescribed medications and having a system in
place to ensure adherence to the regimen.
Mail out provider listing and educational materials.
Orders overthe counter items formembers.
Coordinates necessary services withparticipating ancillary service providers and public
agencies as appropriate to ensure quality, cost effectivecareand reduced readmissions for
Coordinates transition of care between inpatient and other settings withthe practitioner,
Healthcare Services (HCS) staff,and community based agencies, social workers,
hospital/nursing facility discharge planner, and/or other providers as required.
Facilitate appointment with either the Primary Care Physician/Practitioneror treating
Document assessments, care plan updates and planned tasks.
Discuss emergency plan.
Refer complex cases to case management as appropriate based on consultation with the
Molina Health Care Care Review Processor II Utilization Management
Providecomputer entries of authorization request/provider inquiries via phone, mail or
Meet Department productivity standards on a daily basis.
Respond to requests for authorization pf services submitted to CAM department via phone,
fax, and mail according to Molina timeframes.
Contact Physicianofficesto request missing information from authorization requests or
additional information as requested by the medical director.
Meet department quality standards, including inter-rater reliability testing and quality
review audit scores.
Verify member eligibility and benefits.
Determine provider contracting status and appropriateness.
Determine diagnosis and treatment requests.
Verify inpatient hospital census admits and discharges.
Provideexcellent customer service forexternal and external customers.
Maintain confidentiality and comply with Health Insurance Portability and Accountability
Independent Living Systems Claims Reconciliation Specialist Long Term Care Dept.
Responsible forreview,reconciliation and resolution of claims pending.
Documented findings in claims review and report to appropriate departments for resolution,
i.e., contract configuration, provider education.
Adjusted claims as needed according to provider’s contractand member’s eligibility and
Applied special claims procedures and guidelines as established for each type of claim, i.e.
Modified authorizations forclaim processing.
Communicated with Case Managers for approval of services to process claims.
Reviewing member eligibility relating to the members status on the date of service billed.
Applied member benefits, limitations, and exclusions in relation to the service billed.
Handled and followedup on tasks via MicrosoftOutlookon a day to day basis.
Performed research, analysis, and reports on special claim projects.
Assisted in the development of automated solutions to prevent adjudication errors and
Providedquality customer serviceto providers, health plan contracts and internal personnel.
Accessed claims from the work queue and queries claim status, utilizing all appropriate
systems to effectively researchthe claim.
IndependentLiving Systems Care Coordinator Long Term Care Dept.
Assisted Clinical Care Manager and Non-Clinical Care Manager to coordinate interventions
for individualized care plans.
Contacted members as necessary to assist in coordination of services.
Prioritized members according to intensity need and required follow up.
Identified and effectively utilizedhealth plan benefits and community resources to meet the
needs of members and caregivers.
Made appropriate referrals to other programs to address the member’s needs.
Assisted in report production, data collectionand data entry forcare plan management.
Coordinated provision of social services, home & community based services and other
identified services and resources.
Maintained a workingknowledge of, and adheres to applicable federal/state regulations
including but not limited to, laws related to patient confidentiality,release of information
Collaborated withinterdisciplinary care team and facilitates case reviews as necessary.
IndependentLiving Systems HRA Agent Health Risk Assessment
Responsible forthe completion of Assessment for members via telephone.
Ensured that productivity levels are up to par with the rest of the team members and in
meeting the designated quota.
Attended to inbound calls, as needed.
Promoted a customer oriented philosophy as well as upholds the organizations Mission
Replied to member’s questions and inquiries within the scope of practice.
Versatility on the different assessments used (based on individual client).
Answered inquiries by clarifyingdesired information; researching, locating, and providing
JEM Home Health Agency Case Manager Secretary
Answered telephones, tookmessages and/or redirected calls.
Greeted visitors and directed them by maintaining employee and department directories.
Scheduled daily visits for Clinical Managers visiting patients.
Managed Incoming/Outgoing mail, Planof Care and PCP orders.
Followedup on a daily basis withmembers Hospitalization/Discharge.
Organized patient files.
Confirmed proper documentation of notes fromCase managers.
Maintained security by followingprocedures; monitoring logbook; issuing visitor badges.
Education,Certifications and OrganizationAffiliations
American High School Academy High SchoolDiploma