Denise Perez Email and Phone Number

• Oversight of the daily operations of the Claims Department which manages 1.2 million lives and consists of the following Sub Units: Claims Health Plan Unit, Claims Capitated Hospital Unit, Claims IPA Unit, Claims Compliance Unit, Claims Provider Dispute Unit, Claims Special Project Unit, Claims Operations Unit, and Claims Recovery Unit.• Work in collaboration with internal and external personnel to enhance automation for auto adjudication, recommendations on existing or future contracts… Show more • Oversight of the daily operations of the Claims Department which manages 1.2 million lives and consists of the following Sub Units: Claims Health Plan Unit, Claims Capitated Hospital Unit, Claims IPA Unit, Claims Compliance Unit, Claims Provider Dispute Unit, Claims Special Project Unit, Claims Operations Unit, and Claims Recovery Unit.• Work in collaboration with internal and external personnel to enhance automation for auto adjudication, recommendations on existing or future contracts, enhancements to the DOFR logic as it relates to claims adjudication.• Create/enhance workflow processes for the various units in order to optimize production.• Ensure that all sub units in the Claims Department are all working in synergy.• Create Policies and Procedures as needed for Commercial, Medicare, and Medi-Cal products in order to meet the needs of the various clients, and Health Plan regulators.• Monitor departmental guidelines including policies, procedures, desktop procedures, workflow documents and job aids to ensure these documents are current and meet the requirements of all IPA clients and Health Plan regulators. Show less

• Primary responsible for the oversight of the daily operations of Easy Care MSO.• Oversee the Directors and Managers in the various Departments. Departmental Management direct reports are: Claims, Network Relations, Human Resources, Receptionist, Credentialing, Information Systems, Compliance, Capitations and Eligibility, and Membership Services.• Oversee the recruiting, hiring, training and managing of new hires.• Oversee all technology… Show more • Primary responsible for the oversight of the daily operations of Easy Care MSO.• Oversee the Directors and Managers in the various Departments. Departmental Management direct reports are: Claims, Network Relations, Human Resources, Receptionist, Credentialing, Information Systems, Compliance, Capitations and Eligibility, and Membership Services.• Oversee the recruiting, hiring, training and managing of new hires.• Oversee all technology concerns relating to the IPA Module and ensure that a project plan is in place and implemented with the Director of IT.• Streamline processes within the company in order to optimize maximum results and success.• Supervise ECMSO’s operation through coordinating and directing activities which are consistent with established policies, goals and objectives.• Assist President with the recruitment of new clients for management.• Prepare monthly BOD reports and submit to the President of ECMSO for review.• Ensure that all policies relating to the individual departments as well as the company policies are enforced.• Assist President in projects, RFPs, or any other area as needed. Show less

• Primary responsibility was to assist in the creation and development of this new Management Services Organization (MSO). Easy Care MSO was created, approved and implemented within 3 months.• Responsible for the creation of all Medi-Cal, Commercial, and Medicare policies and procedures for the Claims Department ensuring that all policies comply with governmental and accrediting agency regulations.• Responsible for the creation of Job Descriptions based… Show more • Primary responsibility was to assist in the creation and development of this new Management Services Organization (MSO). Easy Care MSO was created, approved and implemented within 3 months.• Responsible for the creation of all Medi-Cal, Commercial, and Medicare policies and procedures for the Claims Department ensuring that all policies comply with governmental and accrediting agency regulations.• Responsible for the creation of Job Descriptions based on the positions needed.• Responsible for recruiting diverse staff based on various needs of the IPA and Lines of Business. (Commercial, Medi-Cal, Medicare, Covered CA, Cal Medi-Connect (CMC).• Passed ALL Claims Pre-delegation Health Plan audits with a score of 100%.• Assisted in the transitioning of an IPA from one MSO to Easy Care MSO.• Continuously review processes for automation and efficiency.• Created the automation of Letter templates required by the various Health Plans in relation to Claim Denials.• Reviewed and assessed previous claims data from transitioning IPA in order to perform various analytics: - Identify possible recovery of monies (TPL, duplicates, other coverage, overpayments, stoploss). - Identify incentives owed based on the various Health Plan Contracts with relation to the IPA - Identify money owed from the Health Plans due to the Affordable Care Act (ACA) Bump. - Calculate and assess pmpm (per member per month) to identify gaps with contracts based on provider specialty and as well as utilization in order to reduce costs.• Work with the various Health Plans to identify gaps in HCC coding, HEDIS, and STAR programs based on the previous claims data received in order to increase capitation payments and incentive payments.• Establish relationships with various vendors and providers for the new IPA. Show less

• Responsible for leading the Claims Department through a complex and rapidly changing claims landscape.• Develop, recommend, and execute claims department strategies and policies leading to departmental and organizational efficiency and regulatory compliance. • Provide day to day management of LA Care Health Plan's Claims Department and the claims recovery unit as well as oversight of claims related outsourced services. • Responsible for ensuring the integrity of all claims… Show more • Responsible for leading the Claims Department through a complex and rapidly changing claims landscape.• Develop, recommend, and execute claims department strategies and policies leading to departmental and organizational efficiency and regulatory compliance. • Provide day to day management of LA Care Health Plan's Claims Department and the claims recovery unit as well as oversight of claims related outsourced services. • Responsible for ensuring the integrity of all claims reporting including those related to on regulatory audits, filings to government entities, as well as reporting for NCQA and HEDIS audits. • Provides strategic and proactive guidance to the organization that address changes within the health care industry related to claims. • Provide senior management with key information regarding the financial risks of provider contracts for the directly contracted product lines as well as the regulatory issues affecting claims administration.• Maintain compliance with all claims regulatory requirements including claims timeliness, payment of interest, forwarding timelines and correct payment requirements. • Create, maintain and monitor departmental guidelines including policies, procedures, desktop procedures, workflow documents and job aids to ensure these documents are current and meet the requirements of L.A. Care.• Maintain compliance with all Plan Partner and PPG mandated requirements including but not limited to, claims payment, Provider appeals and third party recoveries.• Continuous monitoring of work performed by the claims department managers and supervisors. • Provide an environment that engages staff to fully participate in the overall functioning of the unit. Show less

• Lead the Claims Department and Encounter Data Unit in both strategic and operational transformation, responding to the rapid changes in the marketplace.• Manage a multi product line health claim processing shop for both the IPA as well as the MSO, to ensure accurate and timely processing of claims in accordance with vendor contracts, fee schedules requirements.• Assist the Customer Service Department to ensure that provider calls are answered and handled according to departmental… Show more • Lead the Claims Department and Encounter Data Unit in both strategic and operational transformation, responding to the rapid changes in the marketplace.• Manage a multi product line health claim processing shop for both the IPA as well as the MSO, to ensure accurate and timely processing of claims in accordance with vendor contracts, fee schedules requirements.• Assist the Customer Service Department to ensure that provider calls are answered and handled according to departmental policy and Quality standards are continuously maintained.• Responsible for development, implementation and maintenance of departmental policies and procedures for claims processing activities that meet state, federal, and contractual standards and regulations.• Continuously monitor, analyze and improve staff production through process improvement or other corrective actions.• Prioritize and delegate work to the claims staff including monitoring of inventory, turn-around time, claims call center activity and accuracy of claims payment. • Responsible for hiring, training, retraining and maintaining a diverse staff of exempt and non-exempt employees. This includes coaching, developing skills of staff members and conducting performance evaluations • Perform/Analyze monthly reporting to include high-dollar claims, denied claims, refunds, claims with interest payments, special projects, edited claims and other reports as identified to improve the quality of claim processing and identify potential fraud • Serve as departmental contact in dealing with other departments on cross-department projects and/or initiatives as directed by the Executives.• Work collaboratively with other members of management team to meet all departmental goals and objectives • Analyze the claims management system and implement changes to streamline processes and create efficiencies. • Oversee the research and investigation of claims for possible subrogation activities and/or recoupment. Show less

• Develop and implement system flows to improve auto-adjudication of claims payment processes as well as other Departments within the company.• Create and prepare reports setting forth progress, adverse trends and appropriate recommendations and conclusions.• Provide leadership and oversight in the development of new payment policies, claims edits and provider communications in support of accurate and compliant claims payments.• Develop and direct the implementation of strategies to… Show more • Develop and implement system flows to improve auto-adjudication of claims payment processes as well as other Departments within the company.• Create and prepare reports setting forth progress, adverse trends and appropriate recommendations and conclusions.• Provide leadership and oversight in the development of new payment policies, claims edits and provider communications in support of accurate and compliant claims payments.• Develop and direct the implementation of strategies to substantially improve efficiencies and service provided while reducing costs.• Responsible for building/changing business processes, payment policies and configurations driven by changes in regulatory requirements.• Oversee the management of our claims support vendors; dictate work allocation and established performance and improvement opportunities.• Direct and oversee claims activities with the objective of meeting production, timeliness and quality standards to ensure that services comply with governmental and accrediting agency regulations.• Ensure the delivery of superior customer service by providing timely and accurate claims payment and responding to member and provider inquiries and complaints regarding claims processing.• Plan, conduct and direct work on complex projects/programs necessitating the origination and application of new and unique approaches.• Identify major process and service issues and formulate and implement a resolution plan.• Ensure operational issues are identified, and prioritize appropriately and make recommendations to sustain and/or improve.• Continuously review processes for automation and efficiency. Show less

• Managed the Claims Department which handled over 50 IPAs, approximately 400,000 members.• Created processing policies to meet the needs of the various lines of business for each State.• Reviewed all accounts that resulted in payments greater than $25,000.00 for accuracy.• Coordinated meetings with Provider Relations and high profile clients to review any claim disputes or issues.• Created reports monthly to submit to State Regulators and other contracted clients on the… Show more • Managed the Claims Department which handled over 50 IPAs, approximately 400,000 members.• Created processing policies to meet the needs of the various lines of business for each State.• Reviewed all accounts that resulted in payments greater than $25,000.00 for accuracy.• Coordinated meetings with Provider Relations and high profile clients to review any claim disputes or issues.• Created reports monthly to submit to State Regulators and other contracted clients on the progress of the Claims Department.• Created a Training program for the Department which resulted in the consistency of claims processing for the specific Line of Business for the specific client.• Implemented a Telecommute Program for the Department in order to meet the demands of the growing client contracts. Show less