Erica M. Rivera Email & Phone Number

Compassionate and diligent professional accustomed to surpassing expectations in a fast-paced environment with a strong work ethic and satisfaction record. Possess exceptional ability, education, and expertise to navigate the complex healthcare sector and maintain lucrative relationships with key decision-makers. Adept at analyzing and interpreting medical documentation, coordinating with medical providers to ensure care,and preparing and submitting claims to insurance companies. Skilled in fostering positive patient experiences while maintaining cost-efficiency and compliance. Capable of bringing tremendous enthusiasm and awareness in establishing high-value relationships with a commitment to building a culture rooted in trust and mutual respect.

Listed skills include Microsoft Office, Microsoft Word, Microsoft Excel, Icd 9 Cm, and 5 others.

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  Quality Of Care Coordinator

  Delta Dental Ins.

  May 2022 - Present

  •Responsible for conducting critical analysis and responding to quality of care and service complaints and potential quality referrals for all lines of business•Oversees the complaint response process to facilitate timely resolutions and responses•Records all quality of care and quality of service complaints and potential quality referrals initiated by members and internal and or external clinicians•Reviews clinical and dental records for completeness and determines administrative or clinical complaint•Performs research and identifies key policy provisions such as clinical guidelines, plan policies, EOC, regulatory guidelines, and DMHC/DHCS rules and regulations•Summarizes cases including articulation of complainant's perception and present essential information to Dental Consultant for review•Assigns reviews to clinical staff for those requiring clinical reviews•Works with the Clinical Quality Consultants, Dental Consultants, and other clinical staff to ensure that clinical issues are appropriately evaluated•Prepares case files external (including IRE) review of complaints as appropriate•Coordinates on-site assessments and audits•Identifies the root causes of complaints and works with the applicable operational departments to implement an appropriate resolution•Communicates these resolutions to the complainant via telephone or written correspondence•Assists with additional duties as assigned

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  American Intercontinental University

  Specialization In Health Services Administration Management