Jessica Candelo

Adjudicated high-volume, complex claims with 98% accuracy, ensuring compliance with Medicare guidelines (ICD-9/ICD-10) and proper member cost-sharing. Streamlined claims processing and issue resolution by executing process improvements and supporting Grievance & Appeals initiatives. Generated and maintained detailed reporting tools, including monthly Tri-Vendor reports and MOOP tracking spreadshee

Reviewed and processed incoming physician claims by verifying member eligibility, determining benefits, and ensuring alignment with Medicare filing guidelines and compliance standards using CSC and XTCM. Authorized timely claim payments and ensured accurate distribution of funds, maintaining service level agreements and regulatory adherence. Served as backup lead and peer mentor, supporting traini

Processed and adjudicated high-volume physician claims by validating member eligibility, calculating benefits, and ensuring compliance with Medicare policies using claims systems such as CSC and XTCM. Executed accurate and timely claim payments, meeting strict SLAs and regulatory standards while minimizing errors. Acted as backup team lead and knowledge resource, mentoring peers and supporting tra

Responded to high-volume inbound calls from physicians and hospital staff, delivering accurate information on member eligibility, benefits, and insurance coverage while ensuring adherence to Medicare and CMS guidelines. Educated providers on claims processing and billing best practices, resolving inquiries efficiently and guiding on proper submission protocols. Conducted in-depth research on membe

Managed high-volume call flow across 24 phone lines using Citrix and Microsoft Word, including greeting and transferring patient calls and handling time-sensitive physician messages. Served as the primary Spanish-speaking liaison, translating, confirming, and documenting all Spanish-language calls. Coordinated organ donor transplant referrals by reviewing clinical data and engaging with family mem

Received, organized, and maintained medical record charts to support clinical workflows, ensuring all patient documentation was accurately filed and readily accessible. Created and updated patient files in compliance with healthcare documentation standards, leveraging systems such as Medical Manager, Microsoft Excel, and Microsoft Word. Assisted nursing and physician staff by retrieving and enteri

Provided administrative and records support by managing data entry, document imaging, and general office tasks while maintaining efficiency and accuracy. Handled high-volume inbound and outbound calls, including communications with brokers and external partners. Processed and maintained confidential data in compliance with privacy and security protocols, utilizing systems such as Synergy, NetExcha

Obtained a High School Diploma from Leto High School in Tampa, FL. Completed studies in January 2005.