Isavela Fuentes
Interview Availability: Monday to Wednesday and Friday, any time between 8:00
am to 10:00 am CST (Thursday can work if you tell me in advance)
Start Availability: ASAP
Summary
Reliable and hardworking individual who offers fourteen years of experience in
delivering excellent customer service.
Recognized as a great team player with an emphasis on attention to details, bringing
the best out of team members, subordinates, peers and superiors alike.
Offers seven years of insurance background, five of health insurance both HMO and
PPO.
Proficient in using computers and various computer applications.
Ability to work in a fast-paced work environment.
Excellent communication skills both oral and written.
Education
High School Diploma, Oliver Wendell Holmes High School – San Antonio, TX
2 years, No Degree, English Major, St. Mary’s University- San Antonio, TX
Currently enrolled with Miller-Motte College for Medical Billing and Coding
Degree/Certificate
Work Experience
United Healthcare – San Antonio, TX
Advocate 4 Me Representative II
June 2019 to June 2024
Serviced insurance policies (Both HMO for CA mainly and PPO for all states) over the
phone.
Quoted benefits for scheduled procedures.
Checked on referrals and authorizations as needed based on plan.
Appealed denied referrals/authorizations for prescriptions and medical
procedures/specialty doctors based on the requirements of the member’s plan.
Handled claims for medical and pharmaceutical services including but not limited to,
stop pay, re-issue. Appeals as listed above and grievances. First level appeal was done
by us at uhc, 2nd level was the department of managed healthcare for the members
state and the final step would be QIS/grievance. Incorrect ICD10 was the majority of the
claim appeals cases. It could mean the difference between free and 20% coinsurance
after ded. For example, if the member had a colonoscopy done and instead of the
preventive code a different one was put in by doctor’s office, we would out reach to
provider to first clarify and based on info, begin building appeal case.
Appealed denied claims even if the risk was capitated to the medical group if the
member resided in CA with an HMO.
Changed PCP for plans which required it.
Conduent/MMC - San Antonio, TX
Fraud Assistance/Claims
July 2016 to May 2019
Assisted customers with account information related to state benefits (SNAP, TANF,
Unemployment, Child Care, Etc.).
Filed disputes for unauthorized transactions/ updating client on dispute status.
Provided balance and general card information.
Followed all call scripts and quality guidelines to meet weekly coaching goals.
Utilized all tools properly to always verify client identity.
Adhered and obeyed all scheduled shifts, breaks, and lunches.
Nationwide Insurance - San Antonio, TX
Member Care Representative II
May 2013 to June 2016
Serviced insurance policies over the phone.
Added/removed vehicles and drivers.
Sent requests to file FR19 and SR22.
Reduced/Increased coverage on auto policies/home/inland marine/personal umbrella.
Provided information on how to decrease the premium of policies (discounts, quotes,
etc.).
Provided proof of insurance per the request of the
customer/mortgagee/lienholder/leaseholder.
SKILLS:
Medical Treatment/Terminology
Medical Insurance
Medical Coding (Level I CPT, Level II)
Detail Oriented
Customer Support/Service
Health Maintenance Organization (HMO)
Preferred Provider Organization (PPO)
Prescription Drugs
Co-Payments, Co-insurance, Deductible, Out of Pocket
Flexible Spending Accounts
Disability Accommodations
Pharmacy /or Pharmacy backorders
Auto/Home Insurance
Data Entry
Computer Skills
Problem Solving Skills
Multitasking
Telephone Skills
Communication Skills
Claims/Authorizations
Appeals/Grievances (as a caseworker)
COC requests (continuity of care)
COB requests (coordination of benefits)
Disabled Dependent Requests
Set up interpretation Services needed for PCP appointments
Processed fulfilment and correspondence requests as needed
Audited member’s OOP upon request
HONORS & AWARDS:
Presidential Scholarship of $50,000.00, hence ability to attend private university
Graduated as 6th in top 10 of high school class
LANGUAGES:
English- Fluently read, write, and speak.
Spanish- Fluently read and write. Speak, but not proper/correct.
EXTRACURRICULARS:
Guitar
Active sketch artist
Avid reader
WORK AUTHORIZATION: I am authorized to work in the United States.
