ALYSSA GONZALES
Lodi,CA
Summary
A results-driven professional with a Bachelor’s degree in Psychology and a Master’s degree in Human Resource Management. With 6 years of dedicated service at Blue Shield of California, specializing in project management, process improvement, conducting impact analysis, and collaborating with cross-functional teams. Skilled in stakeholder management, workflow optimization, and developing actionable insights through data analysis.
Overview
7
7
years of professional experience
1
1
Certification
Work History
Operations Specialist Medicare/Medicare Supplement, Customer Service Department
Blue Shield of California
03.2022 - Current
- Optimized the Medicare Quality Assurance auditing process, enhancing data accuracy and reporting efficiency, enabling informed decision-making for leadership.
- Generate executive reports analyzing grievance trends, providing statistical tracking and actionable insights for leadership review
- Developed and implemented a streamlined process for managing Provider Termination letters, ensuring 100% compliance with CMS requirements
- Conduct impact analyses on AEP Cycle changes, identifying risks and providing strategic insights to inform business readiness and decision-making
- Develop and maintain process documentation, ensuring timely updates and seamless communication of new procedures across departments for operational excellence
- Collaborate with Enterprise Learning and cross-functional teams to enhance Appeals and Grievance courseware, improving compliance and workforce training effectiveness
- Lead monthly audits with Medicare Compliance, identifying trends in non-compliance and driving strategic remediation efforts for audit readiness
- Partner with business leaders to track project implementation risks, conducting assessments to ensure seamless execution and stakeholder alignment
Case Coordinator, Medicare/Medicare Supplement, Appeals and Grievance Department
Blue Shield of California
05.2021 - 03.2022
- Researched, reviewed, and resolved standard and high priority member grievances and appeals while clarifying issues and educating members in the process
- Responsible for monitoring daily reports to track and close cases timely case with a 98% compliance success rate
- Coordinated with various departments to investigate and provide written findings in accordance with Blue Shield and CMS guidelines
Customer Service Representative, Medicare Department
Blue Shield of California
07.2018 - 03.2022
- Researched, reviewed, and resolved incoming member inquiries including analyzing available programs, determine program eligibility, and connect member to appropriate BSC vendors, Health Advocates, Social Workers, Pharmacy Techs, and Pharmacists
- Assisted in working aged inventory reports to close member cases timely and alignment with CMS compliance requirements
- Collaborated with cross functional departments to provide first-call member resolution while adhering to departmental operations
- Assisted in pilot projects and programs to identify opportunities of improvement prior to project launch
- Supported various teams as floor support to assist with complex member calls and investigative processes
- Interpreted health plan benefits, policies, procedures, and functions to members, providers, and vendors to provide complete investigative resolutions.
Education
Masters - Human Resource Management
University of Arizona
12.2023
Bachelor of Arts - Psychology
California State University, Sacramento
12.2021
Associate degree - Psychology
San Joaquin Delta College
05.2019
Skills
- Data Analysis & Reporting
- Project Management
- Business Process Improvement
- Compliance & Regulatory Expertise
- Stakeholder Engagement & Leadership Communication
- Microsoft Suite, SharePoint, JIRA and Workfront
- Risk and Issue Management
Certification
- Certified Associate in Project Management, Project Management Institute: In-Progress
- Blue Advisor Mentor, 2025
- Strategic Thinking, LinkedIn December 2023
- Individual Contributor Foundations, LinkedIn January 2024
- Data Driven Presentations with Excel and Power Point, LinkedIn March 2024
- McKinsey Connected Leadership Academy, Leadership Essentials, August 2023
Timeline
Operations Specialist Medicare/Medicare Supplement, Customer Service Department
Blue Shield of California
03.2022 - Current
Case Coordinator, Medicare/Medicare Supplement, Appeals and Grievance Department
Blue Shield of California
05.2021 - 03.2022
Customer Service Representative, Medicare Department
Blue Shield of California
07.2018 - 03.2022
Bachelor of Arts - Psychology
California State University, Sacramento
Associate degree - Psychology
San Joaquin Delta College
Masters - Human Resource Management
University of Arizona
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