Summary
Overview
Work History
Education
Skills
Websites
Accomplishments
Interests
Timeline
Generic

Marcella Mireles

Phoenix

Summary

Dynamic and results-driven professional eager to embrace new challenges and opportunities for growth. Strong work ethic, adaptability, and exceptional interpersonal skills contribute to success in diverse environments, whether collaborating within a team or excelling independently. Recognized for thriving without supervision while quickly mastering new skills and concepts. Committed to delivering high-quality results and fostering positive relationships in the workplace.

Overview

7
7
years of professional experience

Work History

Workforce Management Coordinator

Oscar Health Insurance
05.2024 - 08.2025
  • Optimized schedules, forecasts, and other tools to present to management.
  • Prepared and maintained reports and dashboards.
  • Set and adjusted schedules to maintain optimal coverage and service levels.
  • Produced and updated documents, reports, and tracking spreadsheets using Appian, Workday, and Amazon Workday (IEX).
  • Worked with management to develop strategic and tactical plans to meet different requirements.
  • Managed overtime, shift swaps, breaks and PTO requests.
  • Created training materials for new employees to provide information about attendance guidelines.
  • Enhanced team workflows and employee job satisfaction by coordinating communication between managers and employees.
  • Performed ad hoc reporting and analysis to improve overall performance and enable strong understanding of business.
  • Monitored adherence to company policies regarding attendance tracking.
  • Served as a liaison between management and frontline staff, fostering open communication channels that led to increased trust and engagement among team members.
  • Championed process improvements initiatives that streamlined workflows.
  • Implemented contingency plans to ensure business continuity during periods of change or unexpected events, such as staffing shortages or emergencies.
  • Analyzed workforce data to identify trends and implement targeted interventions, increasing employee satisfaction.
  • Developed comprehensive reports for management to track key performance indicators and drive continuous improvement.
  • Cultivated positive working relationships with internal stakeholders through transparent communication practices.
  • Optimized shift rotations while balancing employee preferences with operational needs, resulting in reduced overtime expenses and higher morale levels among the workforce.
  • Coordinated staff training sessions, improving skillsets and increasing overall team effectiveness.
  • Streamlined communication channels with cross-functional teams, enhancing collaboration and productivity.
  • Produced and updated documents, reports, and tracking spreadsheets using Excel, IEX and NICE.
  • Instructed senior leaders on appropriate employee corrective steps.

Claims Examination Processor

Oscar Health Insurance
07.2023 - 05.2024
  • Process incoming work associated with Claims operations following standard operating procedures.
  • Stay in compliance with all applicable laws and regulations.
  • Develop an excellent grasp of the EXAM and PFWA workflows.
  • Develop a comprehensive understanding of the current review processes that currently exist and additional processes needed to improve consistency and quality of review.
  • Contribute to the reduction of the daily inventory.
  • Assist with the escalation and resolution process with internal departments to ensure resolution.
  • Contribute to teamwide goals that support the success of Claims Productions' daily operations.
  • Identified areas where processes can be improved upon to increase efficiency and productivity.
  • Liaised with management to complete special projects and provide support.
  • Maintained accuracy of work by completing deep research and resolving variances.
  • Appointed as a subject matter expert in multiple workflows as well as creating documents for peers to utilize or reference when needed.
  • Received and reviewed incoming documents and materials.
  • Met production targets and tight deadlines by collaborating closely with team members.

Clinical Review Processor

Oscar Health Insurance
07.2021 - 07.2023
  • Receive incoming calls as well as perform outbound communications to insured members, providers, and contracted facilities.
  • Calls also included verifying in-network status, out-of-network status, and eligibility verification.
  • Educate providers through the process of submitting a prior authorization via phone as well as reviewing submissions created through the Oscar provider portal.
  • Create medical and behavioral health authorizations to review for Medicare Advantage, Cigna, and commercial plans.
  • Substantiate online prior authorization inquiries.
  • Utilize EMR for applicable clinical information.
  • Coordinate with nurses and medical directors to assist with members and providers needs.
  • Assist with quality review while working multiple queues and lines of business.
  • Provided feedback to peers as well as providing shadow sessions and being a point of contact for difficult scenarios.
  • Facilitated new personnel training groups and continued the commitment to reiterate the importance of accuracy and compliance within the company.
  • As an internal appeals processor, I investigated the accuracy per query for timeliness, service timing, and urgency.
  • Case build requests while attaching proper documentation for review.
  • Completed a verbal outreach to communicate with members the timeframe for any next steps.
  • Monitored daily workflow to ensure deadlines were met.
  • Maintained strong relationships with internal departments such as nurses, medical directors, and out of network team.

Insurance Specialist

Mckesson
08.2020 - 03.2021
  • Efficiently enroll new patients into the patient support programs.
  • Perform data entry, answer inbound calls, make outbound calls, manage emails and faxing.
  • Maintain service levels in case management, including telephone answer rates and time to initial contact with the patient.
  • Developed and implemented strategies for reducing risk exposures and maximizing profitability.
  • Evaluated customer applications and determined eligibility for coverage based on established criteria.
  • Analyzed financial statements to determine appropriate levels of coverage for clients.
  • Ensured that customer data was kept confidential at all times per applicable laws and regulations.

Patient Care Advocate

Alliance RX Walgreens Prime
08.2018 - 03.2020
  • Stayed up to date with all rules and regulations regarding HIPAA while staying in compliance within the company at all times.
  • Handled high volume inbound calls from patients and prescribers and assisted with shipping and delivery of specialty medication as well as monitor personal KPI (key performance indicators).
  • Assisted Federal Employees with managing their specialty pharmacy benefits and the delivery of their medications.
  • Received incoming calls by way of transfer with concerned members.
  • Reviewed escalations both on and off calls.
  • Deescalated any pending issues to result in requests being resolved.
  • Ran test claims and found a solution to any potential issues to ensure that each patient received their medication on time.
  • High proficiency of Microsoft Office products as well as internal systems including VMware, ScriptMed, IEX, Kronos, and SAP.
  • Used dual monitors to multitask several different internal systems on every call, including but not limited to, outreaching patient financial services, the insurance department, and members health plans.
  • Appointed multiple times to not only train new hire classes but also assist with side by sides in the nesting environment.
  • Coordinated with other healthcare providers to ensure patient safety, continuity of care, and optimal outcomes.
  • Collaborated with insurance companies to ensure coverage of necessary treatments or medications.
  • Maintained accurate documentation of all interactions with patients in accordance with HIPAA regulations.
  • Provided emotional support and guidance to patients and families facing difficult medical decisions.
  • Participated in quality improvement initiatives aimed at improving overall patient experience.

Education

High School Diploma -

The American Academy
08.2023

Skills

  • Time allocation planning
  • Medical documentation oversight
  • HIPAA compliance knowledge
  • Knowledge of clinical terminology
  • Quality assurance
  • Jira
  • IEX expertise
  • Workday system expertise
  • Proficient in NICE principles
  • Quality improvement initiatives
  • Fraud detection and prevention
  • Strategic workforce planning
  • Evidence-based decision making
  • Upholding service standards
  • Meticulous attention to detail
  • Effective troubleshooting skills
  • Trustworthy execution
  • Cross-functional collaboration
  • Versatile in dynamic environments
  • Intrinsic motivation
  • Policy enhancement suggestions
  • Goal-oriented planning

Accomplishments

  • Received exceeding expectations on 2023 end-of-year review.

Interests

  • Coding and Programming
  • Supporting STEM education initiatives and mentorship programs

Timeline

Workforce Management Coordinator

Oscar Health Insurance
05.2024 - 08.2025

Claims Examination Processor

Oscar Health Insurance
07.2023 - 05.2024

Clinical Review Processor

Oscar Health Insurance
07.2021 - 07.2023

Insurance Specialist

Mckesson
08.2020 - 03.2021

Patient Care Advocate

Alliance RX Walgreens Prime
08.2018 - 03.2020

High School Diploma -

The American Academy

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Marcella Mireles