Brian Pedroza Email & Phone Number

Los Angeles, Ca, Us

Los Angeles, California, United States

- Verify member eligibility and benefits via health plan websites and/or other methods as appropriate. - Complete benefit plan builds for all HMO Managed Care plans by completing specification imports with all appropriate benefits (copays, coinsurance, deductibles and MOOP).- Responsible for contacting health plans for benefit interpretations and to acquire clarification for use in design.- Work closely with EIS Personnel on EIS-related projects. - Nurture two-way communication within department and with end-users.- Use Customer Relationship Management tool to connect with internal departments to resolve issues and tasks pertaining to enrollment, eligibility and benefits and adhere to task turn-around times.- Work eligibility work-queues for any eligibility and benefits issues.- Determine coverage filing order using NAIC and CMS guidelines for Coordination of benefits.- Work enrollment audit reports and other system reports to make appropriate eligibility and benefit updates. - Perform root cause analysis to determine issues related to eligibility and benefits or system errors.- Identify issue trends and opportunities for improvement.

- Working knowledge of Epic Care Connect system.- Effectively manage large volume of incoming calls- Greet costumers warmly. Identify and assess customer’s needs to achieve satisfaction.- Provide education/status on referral and claims request.- Handle complaints, provide appropriate solutions and alternatives within guidelines and follow up to ensure resolution. - Troubleshoots patient complaints (i.e., access, service and copay issues, etc.)- Make outbound calls to patients, providers, or vendors to request needed information/documentation.- Investigate patient’s PMG transfer issues such as verifying last dates of service.- Attend meetings as needed and adhere to safety policies and standards.- Perform other duties as directed.

- Responsible for a wide range of analysis regarding benefits; evaluating the costs and benefits- Implementation of co-pays in correspondence to benefits ranging from ER, OP, IP, etc based on CPT codes- Gather, analyze, review, prepare and summarize the Health Plan’s benefits- Prepare daily reports for the department and compile end of day report pf work completed, pending, and adjusting- Consult with appropriate internal/external staff on issues relating to the interpretation and the clarity of benefits- Analyze, research, and resolve benefit-related errors for accuracy and to ensure compliance- Assume other duties as directed

Northridge, California

- Verify eligibility and benefits on all requests from Prior Authorization.- Anticipate our customer needs: Understand the process and the guidelines in order to provide accurate and in timely manner information to Prior Authorization department so they can properly authorized or deny services based on coordinators findings.- Verify financial responsibility for all requests.- Maintain turnaround time compliance in all aspects of the UM process.- Maintain patient confidentiality so that HIPAA compliance is observed at all times.- Recognize when error has been made and immediately reports to appropriate manager.- Communicate appropriately and clearly to management and co-workers.

Reseda, California

- Develop and coordinate basic durable medical equipment donations - Responsible for DME inventory management and thorough knowledge of DME product library- Set appointments with seniors and/or their family members to pick up equipment- Clean and secure the safety of donated and returned medical equipment- Explain functionality, safe use and cleaning of products to client- Process referral intakes- Update and verify insurance information for all patient files.

Pacoima, Ca

- Train newcomers on proper package handling safety- Load and unload packages onto or from delivery vehicles, trailers, conveyor system carts and load gratings while maintaining work safety measures- Utilize hand-to-hand surface methods for all package handling- Scan packages, read labels and charts, verify numbers, memorize information and sort packages accordingly

Los Angeles, Ca

- Assisted the Emergency Management department with the Business Continuity Plan project- Tested and exercised 38 critical departments for safety compliance guidelines- Performed satellite viability and SATRAD testing to pinpoint the best access across a multi-city block campus- Performed “e-rounds” to identify safety issues that needed to be addressed immediately to remain compliant- Attended and lead fire, life, and safety drills across multiple hospital departments and floors

Pacoima, Ca

- Present and sell company products and services to current and potential clients.- Find out the customer's needs- Describe a product's features and benefits- Provide prompt and efficient responses to customers and handle all customers in a friendly and helpful way.

Stevenson Ranch, Ca

- Responsible for receiving merchandise and managing inventory.- Utilize hand-to-hand surface methods for all package handling- Marking merchandise with codes to be identified- Stocking shelves, and helping customers place orders.

Bachelor'S Degree, Health/Health Care Administration/Management

Associate Of Arts (A.A.), General Studies: Social And Behavioral Sciences