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 action plan (CAP)s for further evaluation.• 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 improvements related to protected health information (PHI) in coordination with Fraud Waste & Abuse (FWA). • 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.• Assists with developing and implementing validation tool, tracking tools, auditing tools and other internal databases (MS Access). Distribute training materials in preparation for CMS and DMHC regulatory audits. • Provide feedback to all delegated groups with ICE Claims Information related to critical data management with a focus on quality improvements.• Other projects and duties as assigned.

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 and other departments on claim issues.• Identifies process improvements and correct any system errors identified and to eliminate system errors from reoccurring.• Initiative with a proactive approach to follow-through on multiple projects with little supervision or guidance.• Other projects and duties as assigned.