Nilda Iris Pina

Conducted outreach to EmblemHealth members to address care barriers and enhance overall experience.

Educated members on importance of routine preventive care and regular appointments for chronic conditions.

• Increased Medicare Star ratings and Medicaid Quality Incentive scores through targeted member education.
• Boosted HEDIS/QARR rates by closing clinical care gaps via member outreach initiatives.
• Executed outreach calls supporting Health Outcomes Survey, discussing fall prevention and health-related topics.
• Facilitated connections between members and necessary resources to overcome obstacles to care.
• Promoted awareness of chronic condition management among members and their families.
• Enhanced member understanding of healthcare services available through EmblemHealth.

Verified provider claims for coverage eligibility and payment accuracy.

Analyzed claims to ensure compliance with policies and billing codes.

• Managed client inquiries for health insurance plans, ensuring timely and accurate responses.
  Educated external clients on self-service options and system functionalities.
  Engaged with team to develop best practice procedures for improved efficiency.
  Focused on achieving positive outcomes for constituents and the company.
  Triage and manage multiple priorities while balancing daily activities.
  Resolved customer service and billing complaints through effective communication.
  Contacted customers to address unresolved grievances, referring them to appropriate departments.
  Maintained customer files and databases, ensuring up-to-date information.