• Effectively process pre-authorization requests for all members and ensure accurate determinations based on medical necessity.• Create, review, and analyze utilization data and identify improvement opportunities.• Manage the daily operations and ensure that all processes, programs, and operations of utilization management are fully implemented.• Oversee and perform administrative services necessary to operate while developing improvements to the workflow as needed.• Communicate with the staff both verbally and in writing to convey health plan, contract or operations information to ensure all staff members have a consistent and appropriate knowledge base to perform their duties.• Knowledge of NCQA, DMHC, CMS and other regulatory agency requirements pertaining to delivery of health care in the managed care setting.• Establish collaborative working relationship with CMD to assure a sound Utilization Management program and improve practitioner and member satisfaction.

• Serve as the point of contact for all medical and dental providers in our network. Build and maintain professional relationships at all times with providers to ensure satisfaction. • Educate providers regarding PHA’s policies and procedures related to referrals, claims submission, appeals and other protocols.• Recruit physicians in accordance to network requirement needs and obtain necessary credentialing information for all new and existing providers. Follow up with any providers regarding pending contracts and answer any questions or concerns.• Strategically develop and complete an Annual Provider Network Submission with DMHC for a large expansion with two LOBs. Prior to filing an expansion, completed all DMHC prerequisites working closely with partners and providers. • Planned outreach activities by promoting network expansion to various providers, obtaining 75% of contracts to goal. • Negotiate and renegotiate contracts with physicians/physicians group and update the systems to reflect changes to ensure provider’s applications are correct and expedited.• Investigate and resolve member complaints regarding providers to maintain member and provider satisfaction. • Provide responsive and professional customer service to providers regarding status of medical and dental claims.• Utilize systems to accurately verify member eligibility, explanation of benefits, provider restrictions, and co-pays.• Facilitated other projects in a timely manner and prioritize according to company needs.

• Worked with individual health plans, health systems, and/or other healthcare organizations to analyze needs specifically around population health, quality improvements, and how to realize Return on Investment (ROI) using CCGroup's analytics.• Strategically educated and guided healthcare organizations of analytic products in areas such as physician efficiency measurement, physician quality and effectiveness, and predictive modeling to address members with constant or emerging health across Medicaid, Medicare and Commercial business lines.• Collaborated with internal analysts and other department members to ensure HEDIS and CMS STARs measure specifications were up to date.• Maintained working knowledge of the National Committee on Quality Assurance (NCQA) standards and State and Federal regulations related to accreditation.• Working understanding of ICD, CPT, and HCPCS codes.• Prepared weekly, monthly, and quarterly reports to keep staff informed of current team progress against goals.• Utilized CRM to execute effective marketing programs, activity tracking, data maintenance, and mailing list management.• Offered proactive recruiting assistance to support COO/CIO in determining applicants’ qualifications.• Interviewed applicants; analyzed responses; verified references; and compared candidates’ qualifications to job requirements.• Trained and managed team members and facilitated collaboration in the workplace.

• Strategically managed all projects related to the work of the Center.• Responsible for detailed organizational tasks for Director: managed non-conflicting, overlapping schedules, planned agendas, prioritized, coordinated logistics, facilitated communication, anticipated and met needs. • Fulfill office-related duties: processed communications (email, regular mail, phone); greeted visitors; scanned and filed documents; scheduled use of limited, yet in-demand, facilities. • Served as liaison between the firm, community-based organizations, and external partners.• Screened clients for healthcare-related legal problems, maintaining confidentiality at all times.• Built a strong rapport with clients, following up on cases as needed.• Planned, organized, and oversaw events.• Facilitated communication with Spanish speakers by translating orally and in writing.• Generated data for reports, grants, or internal analysis for use in negotiations, funding, prioritizing, and assessing current practices.

• Liaised with employees, answering their inquiries; made visitors feel welcome.• Processed employment information and verification requests consistent with agency policies and confidentiality requirements.• In a high-turnover environment, evaluated resumes and followed up with the best candidates.• Administered employee benefits: enrolling, processing forms and changes, generating reports, and coordinating open enrollment; reconciling invoices from benefit plan providers; scanning and filing documents.• Assembled and tracked leave of absence and separation documents; ensured compliance and accuracy of all employee files; input data into the Human Resources Information System.• Generated, maintained, and tracked HR reports using HRIS and Excel.