o Conducted root cause analysis, assisted with problem-resolution management as it relates to claims processing, state requirements, and QNXT configuration.o HealthPlan Lead for Business Benefit Requirement system inquiries, collaborating with various high-level stakeholders to implement changes to meet regulations and optimize system.o Drafted Database Configuration for Benefit Requirements, facilitated cross-department collaboration to ensure QNXT system adhered to state regulations in relation provider reimbursements within a timely manner. o Implemented functional process improvements to meet departmental objectives, while strengthening communication and building relationships with various Health Plan Stakeholders. o Validated QNXT claims process configuration adhered to compliance, contracts, and DHCS policies.o Compiled reports, intake forms, grids, resources to improve department function for performances. o Trained and provided day to day support to Data Analysts within Health Plan Operations; Training included Provider Dispute Resolutions, Benefit Requirements, APL integration, systemic discrepancies, and provider reimbursements. o Reviewed Provider Disputes Claims Appeals, validate the integrity of QNXT claims processing system.o Used available data resources to create reports or analysis to provide insights on root cause and drive leasers decision making.o Analyzed business workflows and system needs for adaptations or migrations ensuring that policies and regulations are met.o Experience working with large data sets, drawing insights and presenting complex business scenarios, along with proposed resolutions. o Experience working with Contracts, DOFR, Fee Schedules, SNF, EncoderPro, CEMS, QNXT, MS SQL, Access, Power BI, Salesforce, All Plan Letters, Senate Bills, Medi-Cal Provider Manual, NCCI Guidelines, IHT/CES Edits.

o Analyzed the quality of call interactions for Medicaid members various states and provided associates with performance evaluations, feedback, and resources. o Monitored call center interactions for compliance ensuring that associates abided by company procedures, standards, HIPAA laws. o Assisted Leadership with trends, insights, and compliance issues to further define Quality Assurance guidelines. Responsible for ensuring employee communications aligned with company directive. o Facilitated and participated in weekly meetings with cross-functional team members to further align departments with mutual objectives. o Compiled evaluations, provided advice, support, and resources to improve call performances. o Reviewed internal appeals to maintain accuracy of procedures within the quality department. o Create and maintained Call Queries in NICE for Medicaid and Grievance interactions.o Complied Excel reports and updated SharePoint as apart of reporting duties.

o Answering calls, providing outstanding service, and appropriately directing callers.o Verify identity and eligibility status per QNXT program.o Collect information and properly document all calls into LVM/N-Centarus programs.o Identifying call purpose if call meets Red Flag Criteria in a diligent manner.o Place 911 calls if directed or deemed necessary by Registered Nurse.o Achieving department and individual set performance goals.o Following QA guidelines and meeting QA expectations.o Maintain confidentiality and complying with HIPAA Laws. o Following after-hours protocol for Facility, Pharmacy, On call Nurses and Doctors

o Assisted patients with concerns, appointment coordinating, verifying insurance and billing concerns.o Recognizing opportunities to improve patient relations and problem solving to support patient needs.o Achieving performance goals, while meeting quality assurance guidelines and conversion expectations.o Up selling, promoting marketing campaigns, providing product knowledge and services information.o Generating and distributing EOD/EOW/EOM reports. o Maintaining and updating a complex excel archive.o Updating online dental office schedules.o Resolving inquiries and complaints meticulously & effectively.o Responding to general inquiries, as well as assisting new patients with online registration.o Collaborating with over 32 offices and departments to meet surpass patient expectations, securing successful appointments.

o Heavy volume detailed data entry.o Multitasking between 2-3 applications SKYE, PROENTRY, and E-FILING to accomplish work.o Accountable for completing incoming data entry work on a 24-hour deadline with minimal error.o Prepared, entered and packaged legal documents to be filed with courts and served throughout California. (I.E. Subpoenas, Small Claims, Summons and Complaints, Writ of Execution, Notices and Judicial Foreclosures.)o Advanced check fees for court filings, services, and witness fees. o Trained and assisted the E-filing Department enter orders, scanned/uploaded documents, as well as attached and documented fees in a separate database.o Followed up on file and serve orders, ensuring the promised company deadlines were met.o Responded to customer inquiries, request, and cancelations on orders for each individual case.o Priced individual orders, analyzed documents to avoid court rejection fees, kept detailed notes for special requests; check pointed and sorted documents to appropriate locations. o Endorsing Summons document, to be sent out for service to businesses, individuals, trustees, and public entities.

o Transcribing medical reports, generating medical bills, and requesting medical records.o Managed 3 Doctor’s schedules, 2 employees, and 1 intern.o Scheduling and referring patients to specialty offices and radiological exams. o Medical collections and completed yearly audits for outstanding claims.o Responding to subpoenas for records.o Responsible for over 90 active patients and auditing charts for quality assurance.o Working with attorneys, insurance agencies and other facilities to fulfill patients individual needs.o Answering phones, filing, faxing, mailing reports, and corresponding to letters.o Supervising/updating patient archive of over 1000 files.o On the spot problem solving to maintain an efficient office flow.o Ordering office supplies, medical supplies, and managed vendor appointments. o Maintain confidentiality and comply with HIPAA

o Assigned liaison for a clients account, special handling services required for proofs of service.o Correcting, amending, and following up on proofs of services that are pending court filing.o Identifying data gaps, compiling missing data on proofs of services.o Scanning, index viewing, and sorting data on legal documents.o Faxing, copying, scanning, and preparing large quantities of documents for court filing.o Logging proofs of services, printing, packaging, and filing documents with courts. o Heavy volume and time crucial data entry for multiple clients.