Victoria Tonsall-Mitchell Email & Phone Number

Rancho Cordova, CA, US

• Collaborates with department director to establish department goals and tracking mechanisms
• Engages with eligibility and customer service staff to encourage employee growth and development and to ensure staff is providing the highest quality service with each interaction
• Works closely with other departments, such as claims and utilization management, to ensure that member and provider needs are met, and issues are resolved in a timely and professional manner
• Communicates with provider offices, partner health plans, and external carriers to ensure member data and coordination of benefits information remains current
• Upholds strict company and regulatory standards for privacy, fraud, waste, and abuse

• Promoted within first year with company.Responsible for overseeing front-end eligibility operations, for a population of 100k+ members, across three lines of business -Medi-Cal, Medicare and Commercial.
• Works independently, and directly with management, to identify trends in membership population changes
• Implements reporting mechanisms to track payer information for proper coordination of benefits
• Increased capture of COB information by more than 700% from March 2022 to August 2022
• Coordinates with management to identify departmental goals
• Engages across departments to resolve escalated eligibility concerns

Rancho Cordova, California, United States

• Responsible for supporting daily operations of claims team for California Health and Wellness.
• Works independently, and directly with management, to track inventory of first time and adjustment claims
• Identifies trends related to barriers impacting timely adjudication of claims
• Assigns daily work to team of analysts and tracks through completion
• Conducts one-on-one and small group training
• Resolves escalated and complex claims

Rancho Cordova, California, United States

• Responsible for determining insurance coverage of patients, resolving aged claims, determining applicable adjudication reason code, acquiring necessary information, and providing claim analysis.
• Demonstrating excellent abilities to dexterously navigate Amisys, CenPas, Image Viewer, and TruCare to accumulate the necessary data required for the proper execution of the adjudication processes
• Thoroughly reviewing the policy and contract provisions to figure out if the claim is payable or should be denied
• Determining the current status of medical-related claims through in-depth and comprehensive research and proceeding accordingly
• Ensuring to follow established departmental guidelines regarding charges and payment or denial codes
• Managing and maintaining files, records, and documentation timely and securely

Rancho Cordova, California, United States

• Responsible for researching and correcting TruCare authorizations errors, reporting data, timely updating referral records, and creating inpatient and outpatient authorizations.
• Accurately recorded data before authorizations and processed referrals for submission to clinical staff
• Dexterously compiled data from daily Auth Load Error Report (ALER)
• Processed weekly CM Pends report for CHW CCS claims
• Reviewed, identified, and eliminated TruCare authorization error
• Performed various functions such as compiling data from Auth load error report, processing of daily PACR report and reviewing and processing corrections for claims

Rancho Cordova, California, United States

• Responsible for verifying claims, scrutinizing to ensure treatments and procedures are based on the allowed authorization and eventually approving or denying the claim payment.
• Supported departmental goals by analyzing and adjusting claims
• Researched patients’ eligibility and claims history
• Thoroughly investigated claims in an effort to ensure they were not duplicate request
• Adjudicated medical claims for the Veterans Choice Program by using the knowledge of business rules
• Determined the level of reimbursement based on established guidelines