Manage day to day operations of MMM and PMC Appeals and Grievances Department.Implemented new system for handling appeals and grievance via a workflow and imaging system.Supervison of 20 full time employees.Liason between MMM and PMC Appeals and Grievance Department and CMS Regional Account Managers.Revise upheld cases before submission to Maximus Federal Services and assure cases are submitted within timeframesMonitor Maximus overturn rateImplemented strategies for reducing Members and Providers CTMsActively participated in DVA, ASES, CMS and NCQA audits with excellent outcomesCunducted trainings to several departments in the company about Appeals and Grievances SOP.Perform regular internal audits to assure CMS compliance and to identify compliance issues.Contact between healthplan and the Patient Advocate Office of Puerto RicoParticipated in Administrative Law Judge (ALJ) hearingsResponsible of reporting Member complaints to ASESActively participate on 5 Star programing initiatives

Supervison of 17 Appeals and Grievance Analyst.Manage employee payrollPerform Analysts training and coaching.Monitor Appeals and Grievances timeframes.Managed CTMs on HPMS.Liason between Healthplan and Medicare

Manage day to day operation of the Customer Service department. Responsible for call center reporting and preparation of the Executive Committee call center presentation. Assure compliance with CMS regulations and HIPPA. Supervise call center Agents, perform coaching, staff meetings, call monitoring and prepare Agent scorecards for performance management.