Simone Rivera Email & Phone Number

Researched claims due to a provider inquiry•Create and update existing workflows for teams•Facilitate training sessions for onboarding staff and vendors•Lead weekly vendor conference calls•Troubleshoot system issues for vendors•Point of contact for any cross-departmental issues•Present at town hall meetings with departmental updates•Consultant to the Business Processing Improvement department on streamlining workflows•Prepare and mail audit announcement and release letters for providers•Field problem phone calls from multiple departments•Compile and create member appeal committee cases for the utilization analysts•Performed special projects upon request i.e. present in a communication workshop

Analyzed and researched various types of claims for Medical Director Review •Executed Directors’ determinations on claims•In charge of running daily reports for audit teams•Responsible for appropriately distributing work to the physician outlier vendor, certified professional coders, utilization analysts, and managed care coordinators

Provided excellent customer service to members inquiring about mental health benefits, authorizations, and claims information•Assisted in the creating, updating, and processing of mental health and chemical dependency authorizations thru UNITY systems•Coordinated with clinicians and care managers for the pre-certification of higher level of care admissions for members•Analyzed and transfers all crisis members to clinicians for risk assessments•Assisted members in the referral process thru a database of nationwide providers for mental health and substance abuse related issues•Updated providers and members with current provider status and specialties•Contacted providers and members for all requested account updates and authorization information•Responsible in the updating of member’s files with current name, date of birth and additional demographic information•Adhered to all company and HIPAA policies and restrictions•Handled various light office duties such as faxing, printing and mailing of release of information forms and treatment service reports

Human Resources Management, Human Resources Management/Personnel Administration, General, 3.86

Associate Of Science - As, Business Administration And Management, General