Betsy Lowell Email & Phone Number

Remote

Responsible for accurate and timely maintenance of critical provider information on all claims and provider databases. Maintains critical provider information on all claims and provider databases. Synchronizes data among multiple claims systems and application of business rules as they apply to each database. Validate data to be housed on provider.

Long Beach, CA

• Verify authorizations for medical services and route cases to Medical Directors for NON-PAR and PAR provider appeals. Liaise with claims department to treat claim reviews and escalate adjustments. Review medical.
• Analyze data collected and coordinate with member's treating providers and pertinent departments to resolve member's complaints, for MMP and MAPD line of business.
• Determines member eligibility and utilization history using Molina's membership, claims, prior authorization, and case management complaint tracking systems and standalone databases and tools.
• Prepare and mail resolution decision letters that meet Medicare and Market Place requirements for content and timeliness.
• Prepares Maximus packages when determinations are upheld.
• Prepare and route cases to medical directors for review, for post services NON PAR provider appeals.

Long Beach, CA

• Assisted HICS department while using HIC’s staff and Reviewer Lead, able to read and understand the SSR, Pre Audit and 834 files, able to create and update Pharmacy Caremark accounts and remove restrictions.
• Resolved issues submitted via the Marketplace Escalations inbox SharePoint.
• Enrollment and Premium Payment Issue, Discrepancy, Processing PCP Change, Referrals and Authorizations Inquires. Claims that may have been denied in error or interpreting the outcome of the claims to member or provider.
• Assisted Brokers with discrepancies on member’s accounts worked through BIRT (Broker Support Unit) SharePoint.
• Assisted claims with billing issues and escalations, as well as, contacted collection agencies to provide insurance information to resolve outstanding balances.

Long Beach, CA

• Researched and resolved various claim issues using Division of Financial Responsibility reference tools, provider contracts, established policies and procedures, as well as, other resources as needed or required.
• Proper documentation of all calls received using the Claims Customer Service Log program.
• Provided claim and appeal status to providers and work alongside several departments to resolve claim issues.
• Educated providers, delegated administrators, and others on Molina Healthcare benefit co-pays, policies, procedures, and claim payments and denials.
• Ensure current knowledge on Molina Healthcare policies and procedures, benefits relating to claim payments, and other revised reference material.

Torrance, CA

• Responsible for business functions, clinical operations, and quality assurance activities.
• Manage telephone calls, appointment scheduling (in EPIC), and coding and charge entry, coordination of care services with other physicians or third parties.
• Additional job responsibilities included special projects, processing return mail, filing, scanning, faxing, mass mail-outs, ordering supplies, and any additional duties as assigned.

Diploma, Medical Administrative Assistant

Diploma, Certified Nurse Assistant