Natalie Casales
Miami, FL 33175
786-245-9561 (Cell)
ProfessionalExperienceand Skills
 Highly p...
Molina Health Care Care Review Processor II Utilization Management
 Providecomputer entries of authorization request/prov...
IndependentLiving Systems HRA Agent Health Risk Assessment
 Responsible forthe completion of Assessment for members via t...
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Natalie Casales-Resume

Published on: Mar 3, 2016

Transcripts - Natalie Casales-Resume

  • 1. Natalie Casales Miami, FL 33175 786-245-9561 (Cell) Email: ProfessionalExperienceand Skills  Highly proficient in the use of computers.  Excellent verbal and written communication skills in English/Spanish.  Expert knowledge with computer programs: MicrosoftWord, Excel, Outlook,QNXT,CCA, UMK2, Interqual.  Punctual, fast learner and work well with others.  Provenability to identify, analyze and solve problems effectively despite sudden deadlines and changing priorities.  Comfortable working withAged, Blind, Disabled, and Severely Mentally Ill populations with varied economic and educational circumstances.  Excellent leadership and training skills.  Able and willing to assist co-workers, supervisors and clients in a cooperativemanner.  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 customer service.  Maintain member respect and dignity while displaying maturity, empathy, ethics, confidentiality and professionalism. ProfessionalHistory 2014-Present 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 the member.  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 specialist  Document assessments, care plan updates and planned tasks.  Discuss emergency plan.  Refer complex cases to case management as appropriate based on consultation with the Interdisciplinary team.
  • 2. Molina Health Care Care Review Processor II Utilization Management  Providecomputer entries of authorization request/provider inquiries via phone, mail or fax.  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 Act (HIPPA). 2010-2014 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 benefits.  Applied special claims procedures and guidelines as established for each type of claim, i.e. modifier rules.  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 maximize efficiencies.  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 and HIPAA.  Collaborated withinterdisciplinary care team and facilitates case reviews as necessary.
  • 3. 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 Statement.  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 information. 2008-2009 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 References availableuponrequest

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