Eileen Ramirez

Financial Coordinator Gastro DME

CHILDRENS HOSPITAL OF ORANGE

07.2019 - Current

FINANCIAL COORDINATOR
CHOC | August 2019 - Present | 5 years 9 months | ORANGE GASTROENTERLOGY FINANCIAL COORDINATOR / 08/26/209-CURRENT /ORANGE CA
-DME Coordinator for Gastroenterology helping families with coordinating dme supplies delivery , requesting auths
-Coordinating referrals, scheduling appointments, obtaining insurance verification and benefits, tracking, documenting and communicating the authorizations of status to internal and external providers as well as the patient/family
-Participates in weekly meeting and huddles as needed
-Process request in cerner and ecpet
-Obtaining auth for labs
-Communicating by Teams
- Obtaining auth to PPO, HMO, Medical ,CalOptima and other Government insurances
-Assisting with training with new assciated
-Assisting with insurance payors to see in auth needed for GI procedures and consult
UMA Coordinator
Agilon Healthcare | April 2019 - Present | 6 years 1 month | Anaheim CAProcess Routine & Urgent treatment authorization requests for medical service made by physicians, parents, teachers, social workers, nurses and various agencies,
· Review and authorizes requests for medical equipment and authorizes dispensing of supplies such as drugs, appliances, braces and visiting nurse services.
· Understanding of the requirements to enroll in the program considering the impact of varied diagnoses of medical maladies affecting children, the treatment generally required for the ailments and the guidelines for service, and
· make determinations of medical eligibility and the type and extent of care proposed for California Children Services.
· Determine whether physician's specialty is appropriate to the patient's condition and whether physicians are on State's approved panel.
· Work with the provider to obtain required information to submit to CCS
· calling for records, completing the SAR and submitting, following up on previously submitted cases, creating cases for those accepted into the CCS program. .
· Accurately review, screen and process referrals in accordance with IPA and health plan TAT guidelines and completed daily assignments with accuracy & quality Knowledgeable of the California Children's Service (CCS).
· Submit required CCS application, release authorization while pending SAR. Track UM TAR referrals that were CCS approved conditions
· Work with Health plans to obtain the required SAR's
· Review daily reports for potential members with CCS valid conditions. Understanding of the Early Start Program and Regional Centers, coordinate and process referrals as needed
· Refer patients to specific medical specialists who have been certified by the State Department of Health, California Children Services.
· Participate in case conferences to evaluate treatment proposals and to provide interpretations regarding application of California Children Service policies.
· Review monthly report to capture possible Early Start or Regional Center referrals. Send letter to the PCP and the member informing them of the programs.
· Assist with obtaining required documents for CCS, CPSP and Early Start health plan audits.
· I have knowledge of Managed Care UM procedures Knowledge of the Medi-Cal Linked Programs to include CCS, ESPRC Knowledge of medical terminology, RVS, CPT, HPCS, ICD-10 codes.
· Attends meetings that update eligibility guidelines and spell out the general conditions under which they will operate.
· Process 20-30 cases per day
· Prepare files for health plan audits as needed
· Comply with UM policies and procedures. Annual review of selected UM policies.
Utilization Management Assistant
St Joseph Heritage Medical Group | January 2016 - Present | 9 years 4 months | Anaheim CAResponsibilities include:
• Verifies insurance eligibility and benefits of members
• Reviews and processes referrals for members using principles of utilization review and evidence of coverage guidelines.
• Assists in gathering of clinical information to substantiate requested referrals to determine medical necessity as directed by the lead UMA or nurse.
• Process referrals according to the established SJHH internal process utilizing contracted vendors and providers as determined by the Contracting Department.
• Create and complete service denial letters according to ICE Denial Letter Standards.
• Researches patient eligibility/enrollment, benefits/criteria to determine medical necessity
• Generate and track all patient and physician correspondence related to referrals
• Assists in the denial letter process under the direction of the nurse reviewer or UMA Lead when appropriate. Initiates Information Member Notice based on benefit or eligibility.
• Maintains files and documentation according to CMS departmental standards.
• Assists in documents to report statistics monthly, as required by the Health Plan, and as requested by the department supervisor.
• Identify and communicate through established protocols any non-compliance with Utilization guidelines
• Interfaces with multiple disciplines and departments to facilitate information gathering in providing services to our members.
• Attends department meetings as required and requested by the department supervisor.
• Calls members regarding notification of referral status or to gather additional information.
• Research and assist in the resolution of patient appeals, grievances, and complaints by gathering necessary clinical
information and responses as appropriate under the supervision of UM Clinical Manager.
• Timely response and appropriate communication with the SJHH- Customer Service Department for all issues related to the referrals process.
• Participates in committee meetings, as deemed necessary
Financial Coordinator
Children’s Hospital of Orange County - Primary Care Clinic | January 2007 - January 2016 | 9 years | Orange CA.Work collaboratively with the PCCs to review initial care plans for patients
· Facilitate patient education per provider orders and telephone screening with documentation per scope
Experience working with children with disabilities and their parents understanding procedures and treatments
· Schedule in-home and outpatient supplies and equipment(Nebulizer, Durable Supplies )
· Collaborate and communicate with the member, family, significant other(s), physicians, Health Network (HN) designee and other health care providers to support and accomplish goals identified on the individualized care plan in all care settings
· Understand confidentiality and the legal and ethical issues pertaining to case management.
· Proficient in Medicare and Medicaid (Medi-Cal) services and regulations
· Receive cases via fax, phone, or electronically and enters the new case information into the Facets and Guiding Care systems.
· Verify eligibility, gather medical records, and follow up on phone calls as directed. Document all contacts and case information in the appropriate Facets and Guiding Care scripts or activity as appropriate.
· Perform data entry into the appropriate databases for monitoring and tracking, trending of cases and other relevant databases as needed. Provide customer service to providers and members.
· Adeptly utilize and access computer programs – both Microsoft Office applications and job-specific applications like CalOptima, CHOC Health Alliance, CCS for prior authorization, HMO, PPO and Medical.
· Utilize prior authorization protocols to determine when to refer matters to a licensed staff person
· Knowledge of guidelines and regulations relevant to case management and utilization management within the assigned area
· Maintain and ensure confidentiality of patient information
· Knowledge of HIPPA and JCAHO Guidelines including Protected Health Information privacy requirements
· Knowledge of ICD 10 and CPT codes
· Other duties as assigned by management
Patient Access Representative
Children’s Hospital of Orange County - Primary Care Clinic | January 2004 - January 2007 | 3 years | Orange CA.Receives, collects, verifies, records, updates and distributes patient demographic, physician and financial information in accordance with standards and guidelines
· Provide payment options for services rendered, accepts payments.
· Coordinates and verifies insurance benefits and eligibility on all patient accounts
· Explains authorizations and referrals for patient services to ensure timely payment
· Ensure that all documentation and verification required is documented in patient account at the time of visit.
· Request and collects monies from patients and documents accounts according to policy
· Enter data electronically on patient charges and orders; balances and maintains cash drawer and daily deposit.
· Answer verbal and written requests in accordance with HIPAA guidelines and departmental procedures
· Responds to requests for patient financial information; investigates concerns/issues; and may refer customers to appropriate hospital resources.
· Explains consent forms and obtains patient signatures in accordance with all applicable state and federal insurance regulations
· Obtain current physician orders to accompany patient chart
· Receives and logs patient articles for safekeeping in accordance with internal procedures.
· Performs administrative support duties including meeting and greeting patients, telephone/communications escort services and hospitality assistance.
· Performs related duties as required.
Submitted claims to insurance companies on same day as patient treatment.
Answered questions over phone and in-person regarding billing, scheduling and treatment.
Maintained a high level of confidentiality when handling sensitive financial information and employee records.
Increased departmental efficiency, implementing standardized procedures for all financial coordinator tasks.

Summary

Overview

Work History

Financial Coordinator Gastro DME

Education

High School Diploma -

Skills

Languages

Timeline

Financial Coordinator Gastro DME

High School Diploma -

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