Rhonda Ramos
@rhondaramos
Committed Lead Specialist with exceptional decision-making skills.
United StatesWhat I'm looking for
I am a dedicated Lead Specialist with extensive experience in medical administration, particularly in Medicare and appeals processes. My career has been marked by a commitment to resolving complex issues for members and providers, ensuring compliance with CMS regulations, and maintaining high-quality standards in all my work.
Throughout my tenure at Molina Healthcare, I have successfully conducted research to address CTM complaints, submitted appeals for medical claim denials, and provided education to members and providers regarding grievance and prior authorization processes. My strong communication skills and ability to multitask have allowed me to thrive in fast-paced environments while delivering accurate and timely resolutions.
With a solid foundation in medical terminology, insurance verifications, and office management, I am passionate about improving patient care and streamlining administrative processes. I am eager to bring my expertise and proactive approach to a new role where I can contribute to a team focused on excellence in healthcare administration.
Experience
Work history, roles, and key accomplishments
Lead Specialist for Medicare A&G
Molina Healthcare
Jan 2021 - Present (4 years 8 months)
Conducted extensive research to resolve all CTM complaints received from members and providers directly from Centers for Medicare and Medicaid Services (CMS), including appeals, grievances, and all member/provider issues reported to CMS. Gathered all necessary data to submit appeals for medical claim denials along with medical records and supporting documents within allowed time frames.
Prior Authorization Coordinator
Phyz Healthcare Solutions
Jul 2020 - Present (5 years 2 months)
Gathered medical documentation to submit prior authorizations for injectables to healthcare insurances. Submitted appeals for any and all medical claim denials along with medical records and supporting documents within allowed time frames.
Appeal & Grievance Representative
United Healthcare Medicare & Retirement Department
Aug 2014 - Present (11 years 1 month)
Gathered, analyzed, and reported documentation for verbal, written, and expedited member and provider complaints, grievances, and appeals. Input data and maintained records in various computer programs and databases, ensuring accurate and timely completion of cases.
Patient Care Coordinator
Community Action Corporation
Feb 2012 - Present (13 years 7 months)
Provided safe, direct patient care in a community health setting with PCP and OB/GYN physicians. Coordinated referrals, prior authorizations, and/or follow-up care and insurance verification.
Education
Degrees, certifications, and relevant coursework
Coastal Bend College
LVN Program, Vocational Nursing
2009 - 2010
Completed the LVN Program at Coastal Bend College. This program provided foundational knowledge and skills for licensed vocational nursing.
Alice High School
High School Diploma, General Studies
Graduated from Alice High School. This foundational education prepared for further studies and professional development.
Tech stack
Software and tools used professionally
Availability
Location
United StatesAuthorized to work in
Job categories
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