Daniel Maclang Jr. Email & Phone Number

Anaheim, California

Cypress, CA

• Perform Annual/Quarterly claims information review, data review, initiate recovery process review for preparation efforts with a CMS and/or DMHC regulatory audits.
• Monitors UnitedHealthcare’s delegated Medical Groups and Hospitals compliance with applicable regulatory requirements. Initiate a cure period process to address the deficiency identified and/or submit a corrective.
• Perform delegated performance on-site risk assessments to observe the claims processes, templates are accurate and delegate policy & procedures are within the regulatory standards and provide guidance on process.
• Provide audit result communications to internal & external departments including a full assessment report, result letters, and an annual/quarterly performance summary.
• Provide feedbacks to Operations Executive Committee related to consecutive non-compliant results within the required timeframe.
• Develop and maintain a close relationship with organizational and delegate personnel by providing guidance and education to maintain compliance.

El Segundo, CA

• Conduct daily reviews of claims processed by internal auditors and examiners.
• Audit auto adjudication of claims (system process), programs and carve-outs performed in the claims department (i.e. member billing, reinsurance, etc.). Performs focused audits as needed.
• Analyzes and reviews QA processing performance indicator reports.
• log all totals related to claims payment errors and examiner productivity for reporting purposes as established in the Claims Policies and Procedures.
• Works closely with management, Trainer, and Provider Relations Department to identify any training opportunities to the provider community and the Claims unit.
• Collaborates with management and Recovery Specialist regarding overpayment of claims that may need to be recovered and to eliminate overpayments from reoccurring. Serve as a resource to Management, Customer service, UM.