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 • Leads up-skilling and cross-training opportunities for Eligibility Specialists and Customer Service Representatives• Resolves failed claims and data mapping errors

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 • Engages across departments to resolve aging claims inventory

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• Ensuring to deliver the assigned project timely and effectively

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• Tracked and delivered daily status of authorization errors for other departments to ensure prompt correction and made sure Trucare authorization errors are eliminated and corrected in an organized and timely manner

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 • Created accurate reports and statistics by entering claim data via the vertexing process