BA
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Responsible, hardworking and motivated Healthcare professional with over 8 years Provider and Member management experience at a Managed Healthcare Plan. Well-versed in DHCS/CMS policies and regulations, NCQA HEDIS quality measures, provider credentialing and contracting, Claims processing, claims adjudication, provider disputes and grievances. Experienced in building and maintaining a great relationship with provider and specialist network.
Experience in managing Joint Operating Committee (JOM) meetings. Proficient knowledge with Independent Practice Associations (IPA).
Provider Relations Representative - Inland Empire Health Plan - Rancho Cucamonga
(2018-04 - 2021-07)
Managed primary care and specialist providers located in assigned territory. Managed an Independent Practice Association (IPA). Managed assigned Federal Qualified Health Care Clinics (FQHCs). Trained providers manage health care policies and incentive programs. Assisted providers with claim inquiries, provider dispute resolutions and encounter data submission process. Updated provider demographic data in the company system. Work as a liaison between providers and various IEHP departments.
Provider Service Representative II - Molina Healthcare - Rancho Cucamonga
(2016-04 - 2017-11)
Managed primary care, specialist, ancillary groups, skilled nursing facilities, home health and behavioral health providers in assigned territory. Managed several Independent Practice Association groups. Assisted providers with grievances and appeals. Submitted provider dispute resolutions on behalf of the provider. Reviewed credentialing applications. Processed provider demographic updates. Conduct new provider orientations.
Meetings with assigned IPAs. Work as a liaison between provider and Molina departments.
Provider Services Representative I - Molina Healthcare - Pomona
(2015-04 - 2016-04)
Supported the Provider Service Department with assigned tasks. Managed Independent Practice Association groups. Managed ancillary groups. Educated providers on claims, authorizations, benefits and incentive programs. Reviewed credentialing applications and updated provider demographic information in the company system. Assisted with hospital and urgent care inquiries. Assisted with Joint Operational Meetings and transcribed meeting minutes.
Customer Service Representative III - Molina Healthcare - Long Beach
(2014-03 - 2015-03)
Responded to telephone inquiries from Dual Choice (Medi-Medi) and Dual Opt out members. Tracked incoming calls in the company system.
Members of HEDIS alerts. Educated members of their plan benefits and verified CPT codes. Submitted eligibility requests. Submitted grievances and appeals on members behalf. Addressed billing inquiries. Processed transportation, linguistic and continuum of care requests. Processed primary care provider changes. Provided medical and pharmacy authorization status. Verified eligibility. Assisted in scheduling appointments.
Customer Service Representative I - Molina Healthcare - Long Beach
(2013-03 - 2014-03)
Responded to telephone inquiries from Medi-Cal and Marketplace members. Tracked incoming calls in the company system. Educated members of HEDIS alerts. Educated members of their plan benefits and verified CPT codes. Submitted eligibility requests. Submitted grievances and appeals on members behalf. Addressed billing inquiries. Processed transportation, linguistic and continuum of care requests. Processed primary care provider changes. Provided medical and pharmacy authorization status.
Case Manager & Administrative Assistant - Intercommunity Child Guidance Center - Whittier
(2011-07 - 2012-06)
Assisted homeless families find permanent housing. Conducted Bio-Psycho-Social evaluations. Completed the client intake process. Tracked clients progress and overseen clients participation in various community programs. Conducted weekly in-home meetings. Educated clients on basic life skills and empowered clients to become self-sufficient. Maintained comprehensive case notes. Enrolled clients in healthcare services. Networked with property management companies and supportive services agencies.
Executive Assistant & House Manager - Rio Hondo Temporary Home - Norwalk
(2007-02 - 2011-06)
Assisted the Executive Director and Clinical Director with special projects, clerical duties, research and analyzed data. Reviewed and submitted grant requests. Planned and coordinated events. Worked as a liaison with government agencies. Assisted with client cases, maintained case notes and progress reports. Conducted House Management responsibilities.
BA - History and Chicano Studies - University of California Santa Barbara
