Marlene Shaw
Murrieta
Summary
Dedicated professional with a strong history of determining eligibility and resolving complex cases, consistently delivering successful outcomes. Collaborates effectively with clients to devise and execute strategies that optimize services and benefits. Possesses a talent for problem-solving and adeptly identifying solutions that align with clients' needs. Demonstrates a high level of skill in navigating challenges and providing tailored solutions to meet client objectives.
Overview
12
12
years of professional experience
Work History
DPSS Eligibility Service Clerk
Riverside County
04.2024 - Current
- Data entry, ten-key data entry, and shorthand documentation for customer’s demographics.
- Switchboard telephone assistance to customers for DPSS programs.
- Support services for identifying, pre-sorting, opening, date stamping, and routing of all incoming business correspondence.
- Knowledge of CalSAWS and Cisco Finesse software.
- Computer literate with knowledge of Microsoft applications.
- Processed and certified documents for accuracy and compliance with government regulations.
- Skilled at working independently and collaboratively in a team environment.
Seasonal Talent Acquisition Interview Team Associate
Macy’s
09.2023 - 11.2023
- Interviewed applicants and explained scope of different available benefits.
- Communicated with people from various cultures and backgrounds on application process.
- Assisted clients with accurate eligibility form, application and document completion.
- Established databases to track, analyze and automate eligibility application processes.
- Organized professional with expertise in managing resources and optimizing performance. Proficient in providing valuable insights and supporting decision-making processes. Committed to enhancing productivity and contributing to overall success.
Referral Specialist 1
Anthem, Inc.
02.2021 - 04.2021
- Acts as a liaison between the hospital, health plans, physicians, patients, vendors, and other referral sources.
- Assisted with completion of referral forms and verified data accuracy and completion
- Verifies insurance coverage and completes the pre-authorization process for radiology and other imaging exams (CT, MRI, MRA, PET, et.)
- Coordinated with medical staff and patients to find cost-effective options for services.
- Called insurance companies to get precertification and other benefits information on behalf of patients.
Credentialing Coordinator
Nvision Eye Centers
10.2019 - 01.2020
- Data entry of the Credentialing data in MD-Staff included CVO information.
- Identify issues that require additional investigation and evaluation, validate discrepancies, and complete appropriate follow-up.
- Coordinated the credentialing and re-credentialing of providers participating in the vision & medical health plans.
- Responsible for tracking and updating expiring provider credentials, including state license, DEA, and annual training programs.
- Conducted follow-ups with health plan on credentialing, re-credentialing, and demographic updates.
- Conducted primary source verifications such as background checks and board certifications.
Data Entry Clerk
Medical Professionals
11.2017 - 01.2018
- Data entry, ten-key data entry, and shorthand documentation for patients’ demographics.
- Insurance verification, medical & surgical coding services, medical collections invoices, account receivables invoices, and negotiated claims.
- Knowledge of medical terminology, insurance, and ICD/CPT codes.
- Knowledge of medical software.
- Computer literate with knowledge of Microsoft applications.
- Onsite assignment at RX Transcription & Coding
PIM Coordinator
Medical Professionals
05.2017 - 08.2017
- Liaison between Prospect Medical IPAs and contracted health plans and manage provider data.
- Responsible for the submissions to contracted health plans for applicable networks.
- Manages requests/inquiries that come from health plans as well as other departments.
- Manages validation of provider rosters, verifying the accuracy and ensuring roster completion.
- Maintaining accurate audit files and performing file reviews.
- Onsite assignment at Prospect Medical
Associate HIM Representative
St. Joseph Heritage Healthcare
12.2015 - 10.2016
- Support services for identifying, pre-sorting, opening, date stamping, batching, and routing of all incoming business correspondence.
- Ensure compliance and timeliness with AB1455.
- Departmental policy and procedure.
- Network department rejects claims.
- Teleform- scan, and QA claim for verification.
Support Services Clerk
Medical Professionals
10.2015 - 12.2015
- Responsible for identifying claims.
- Pre-Sorting claims.
- Opening mail.
- Date stamping claims.
- Batching and routing all incoming business correspondence for all professional and institutional HMO claims.
- Onsite assignment at St. Joseph Healthcare
Customer Service Representative
OptumRX
04.2013 - 06.2015
- Provided telephone assistance regarding various aspects of processing pharmacy claims to members, pharmacists, & physicians.
- Answered benefit eligibility questions and prescription status inquiries.
- Determined appropriateness of overriding pharmacy claims edits and error messages.
- Educated members, pharmacies, & physicians on benefits, use of plan, formulary, copay, and claims, and other inquiries.
- Assisted the Prior Authorization Department with members, pharmacies, & physicians initiating prior authorization for medications.
Education
Bachelor of Science - Health Management
Northeastern Unversty
12-2022
Certificate - Fngerprntiing
Riverside County
California10-2024
Certificate - Provder Enrollment Specialist
Decision Health
02-2020
Certificate - Medical Billing And Codling
ABC Career Technical Education Center
02-2012
Certfcate - Medical Terminology
ABC Career Technical Education Center
06-2011
Skills
- Data entry expertise
- Attention to detail
- Client engagement strategies
- Resource information
- Talent engagement strategies
- Strong verbal communication
- Experienced with Microsoft Office applications
- Candidate assessment
- Data confidentiality
Timeline
DPSS Eligibility Service Clerk
Riverside County
04.2024 - Current
Seasonal Talent Acquisition Interview Team Associate
Macy’s
09.2023 - 11.2023
Referral Specialist 1
Anthem, Inc.
02.2021 - 04.2021
Credentialing Coordinator
Nvision Eye Centers
10.2019 - 01.2020
Data Entry Clerk
Medical Professionals
11.2017 - 01.2018
PIM Coordinator
Medical Professionals
05.2017 - 08.2017
Associate HIM Representative
St. Joseph Heritage Healthcare
12.2015 - 10.2016
Support Services Clerk
Medical Professionals
10.2015 - 12.2015
Customer Service Representative
OptumRX
04.2013 - 06.2015
Bachelor of Science - Health Management
Northeastern Unversty
Certificate - Fngerprntiing
Riverside County
Certificate - Provder Enrollment Specialist
Decision Health
Certificate - Medical Billing And Codling
ABC Career Technical Education Center
Certfcate - Medical Terminology
ABC Career Technical Education Center
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