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Rhonda Ramos

@rhondaramos

Committed Lead Specialist with exceptional decision-making skills.

United States
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What I'm looking for

I am looking for a role that values teamwork, offers growth opportunities, and allows me to enhance patient care.

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

MH
Current

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.

PS

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.

UD

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.

CC

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

CC

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.

AS

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

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Rhonda Ramos - Lead Specialist for Medicare A&G - Molina Healthcare | Himalayas