Melissa Cipolla Email & Phone Number

Greater New York City Area

•Provides written acknowledgment of all member and provider correspondence. Reviews all receipts and applies various regulations to appropriately classify the inquiry. Makes critical decisions regarding research and investigation to appropriately categorize and resolve all inquiries.•Classifies and codes ESaws inquiries appropriately, and enters all actions taken in investigation for auditing and reporting purposes. Prepares cases for medical and administrative review detailing the findings of their investigation for consideration in the plan’s determination.•Interfaces with departments, Delegated Entities, Medical Groups and Network Physicians to ensure timely resolution of cases.•Prepares written responses to all member and provider correspondence that appropriately address the complainant’s issues and are structurally accurate.•Monitors daily and weekly pending reports and personal SAWS worklists, as well as make necessary follow-up calls to internal and external entities to ensure that cases are completed on or before the applicable timeframe.•Conducts thorough investigations of all member and provider correspondence by analyzing all the issues involved and obtaining responses and information from internal and external entities.

Greater New York City Area

• Located available provider (therapy and MD) appointments for members at the request of a care manager (social worker).• Located available in-network patient beds for members to be transferred from out of network facilities.• Followed up with members after discharge at the request of a care manager.• Answered incoming calls providing professional and knowledgeable customer service to facilities who wanted to receive authorization for a patient to be admitted to a hospital/ outpatient program.• Obtained community resources when a member needed additional support besides utilizing their benefits through MHN.

Greater New York City Area

• Responded to members, providers and hospital inquiries, collected demographic and preliminary clinical information. Verified eligibility and gave outpatient provider referrals to members.• Explained benefits and authorization procedures to members, providers and hospitals and accordingly, authorized EAP and outpatient managed care treatment.• Took appropriate steps to resolve a variety of customer service issues regarding provider relations, customer complaints, eligibility questions and claims issues.• Trained and mentored several new intake specialists.