Ma Iran Macativo
Healthcare Insurance Specialist
Las Pinas City,National Capital Region
Summary
Results-oriented and highly experienced Health Insurance Representative with 7 years of expertise in providing exceptional customer service and navigating complex insurance processes. Adept at explaining policy details, assisting clients with claims, and optimizing insurance coverage. Seeking to leverage my extensive industry knowledge and proven track record to contribute to the success of a dynamic insurance organization.
Overview
7
7
years of professional experience
7
7
years of post-secondary education
2
2
Certificates
Work History
Provider Advocate
Optum Global Solutions
Muntinlupa City
03.2022 - Current
- Verify the patient's insurance coverage and eligibility status.
Explain the patient's benefits, including details on copayments, deductibles, coverage limits, and in-network providers. - Provide information on any required referrals or pre-authorization processes.
- Clarify any specific requirements or restrictions related to the patient's insurance plan.
- Assist in obtaining the necessary authorization forms and documentation.
- Review the reason(s) for claim denial provided by the insurance company.
- Determine whether the denial is valid or if it can be appealed.
- Maintain records of claim denials and resolutions for future reference.
- Ensure that all interactions with providers and insurance companies are well-documented.
- Adhere to strict compliance with healthcare regulations, including HIPAA, to safeguard patient information.
- Continuously communicate with providers to keep them informed about changes in insurance policies, prior authorization requirements, and common reasons for claim denials.
Member Advocate
Optum Global Solutions
Las Pinas City
05.2019 - 03.2022
- Address member's inquiries related to plan benefits, coverage options, enrollment, and premiums.
- Educate beneficiaries on the specifics of their Medicare Advantage plans, including services covered, cost-sharing, network providers, and prescription drug coverage.
- Explain any changes in plan benefits or premiums and help members understand how these changes may affect them.
- Assist members in the enrollment process, including helping them understand their options, completing enrollment forms, and verifying eligibility.
- Handle inquiries related to claims status, including explanations of benefits (EOBs) and out-of-pocket expenses.
- Assist with billing inquiries, such as premium payments and explanations of charges.
- Address and document beneficiary complaints or grievances regarding their Medicare Advantage plans. Follow established protocols for escalating and resolving issues in a timely manner.
- Stay updated on Medicare regulations and policy changes to ensure accurate and compliant communication with members.
Ensure compliance with healthcare privacy regulations, such as HIPAA. - Use customer service software and databases to access member's information, track interactions, and provide accurate responses. Assist beneficiaries with online tools and resources related to their plans.
- Demonstrate empathy and active listening skills when interacting with members, who may have varying healthcare needs and concerns. Communicate complex information in a clear, understandable manner.
- Maintain detailed records of member interactions and any actions taken to address their inquiries or issues.
Member Service Advocate
Everise Philippines
Taguig City
04.2016 - 05.2019
- Address member's inquiries related to plan benefits, coverage options, enrollment, and premiums.
- Educate beneficiaries on the specifics of their Medicare Advantage plans, including services covered, cost-sharing, network providers, and prescription drug coverage.
- Explain any changes in plan benefits or premiums and help members understand how these changes may affect them.
- Assist members in the enrollment process, including helping them understand their options, completing enrollment forms, and verifying eligibility.
- Handle inquiries related to claims status, including explanations of benefits (EOBs) and out-of-pocket expenses.
- Address and document beneficiary complaints or grievances regarding their Medicare Advantage plans. Follow established protocols for escalating and resolving issues in a timely manner.
- Stay updated on Medicare regulations and policy changes to ensure accurate and compliant communication with members.
Ensure compliance with healthcare privacy regulations, such as HIPAA. - Use customer service software and databases to access member's information, track interactions, and provide accurate responses.
- Assist beneficiaries with online tools and resources related to their plans.
- Demonstrate empathy and active listening skills when interacting with members, who may have varying healthcare needs and concerns. Communicate complex information in a clear, understandable manner.
- Maintain detailed records of member interactions and any actions taken to address their inquiries or issues.
Education
Bachelor of Science - Medical Technology
University of Perpetual Help System Dalta
Las Piñas City 06.2002 - 04.2009
Skills
Claims reporting systems
Familiar with commercial and private insurance carriers
Familiar with Medical Coding
Familiar with Medicare and Medicaid
Familiar with EHR/EMR
Provider support
Provider Relations
Insurance authorization
Prescription Coordination
Claim research
Medical terminology
Retro-Authorizations
Benefit Coverage
Familiar with medical scribe
Certification
HIPAA certified
Timeline
HIPAA certified
09-2023
Medical Virtual Assistant
09-2023
Provider Advocate
Optum Global Solutions
03.2022 - Current
Member Advocate
Optum Global Solutions
05.2019 - 03.2022
Member Service Advocate
Everise Philippines
04.2016 - 05.2019
Bachelor of Science - Medical Technology
University of Perpetual Help System Dalta
06.2002 - 04.2009