Amber M. Cook
Folsom
Summary
Results-oriented professional with over 17 years of experience in regulatory compliance, quality assurance, grievance and appeals coordination, and process improvement in the healthcare industry. Skilled in managing complex cases, analyzing data, and ensuring compliance with Medicare, Medicaid, and other regulatory requirements. Experienced in mentoring teams, conducting root cause analysis, and implementing corrective actions to address operational challenges. Proficient in preparing audit files, supporting regulatory audits, and driving cross-departmental collaboration to enhance performance. Strong communicator committed to compliance, customer satisfaction, and continuous improvement. Ready to apply extensive expertise to a new, impactful role.
Overview
22
22
years of professional experience
1
1
Certification
Work History
Quality Assurance Analyst
Delta Dental of California
Rancho Cordova
01.2022 - Current
- Review, analyze, and compile operational reports and procedural data to evaluate performance and ensure full compliance with applicable regulatory standards
- Assess and validate group and system parameter tables or call handling procedures to ensure the accuracy of all changes and alignment with established processing rules
- Maintain department tracking logs and generate routine monthly and quarterly audit/performance reports to monitor compliance and operational efficiency
- Lead calibration sessions and collaborate with Supervisors and Training teams to identify training opportunities and enhance the quality of operational performance
- Facilitate root cause analysis sessions to identify compliance gaps and drive process improvements, ensuring operational effectiveness while maintaining adherence to regulatory requirements
- Conduct knowledge-sharing sessions to empower teams in addressing compliance gaps, promoting a culture of continuous improvement and adherence to regulatory standards
Senior Grievance and Appeals Coordinator
Delta Dental of California
Rancho Cordova
01.2021 - 01.2022
- Manage case assignments including appeal review scheduling, point of contact for appeal requester to respond to questions concerning the appeal process, quality assurance process for appeal resolution letter, and liaison for functional inter-departmental dependencies
- Research monthly metrics to identify trends and areas of potential quality improvement report any potential problems
- Perform case review audits and monitor specialist and representative case inventory
- Develop a working familiarity with applicable regulatory and accreditation requirements
- Contributes to team-wide goals to improve processes and integrates additional functions into our daily operations
- Provide support for regulatory audits and manage CDPHP audits, including preparing case files, conducting case reviews, performing root cause analysis, and developing and implementing mitigation plans
- Contribute to team-wide goals to improve processes and integrate additional functions into our daily operations
- Represent Delta Dental and address questions and concerns to the Administrative Law Judge during Medicaid and Medicare fair hearings for appeal determinations
Grievance and Appeals Specialist
Delta Dental of California
Rancho Cordova
01.2017 - 01.2021
- Record and resolves all provider and member complaints and inquiries initiated by local, State, and Federal regulatory agencies, as well as governmental contracted entities into the company tracking system
- Identify the root causes of complaints and works with the applicable operational departments to implement an appropriate resolution - departments include but are not limited to Finance, Enrollment, Claims, Provider Relations & Contracting, Member Services, Medical Management, and Product Management
- Resolves all Center for Medicaid and Medicare provider and member complaints and inquiries
- Coach the G&A specialists in response to customer issues, complex inquiries, and difficult situations
- Communicate resolutions to the requesting agency via telephone or written correspondence
- Assist the department in maintaining, tracking, resolution outcome, and following up on all regulatory directives received from State regulatory and federal regulatory
- Extract complaints data to identify trends and patterns and performs appropriate analysis and translation of such data
- Participate in client and regulatory audits
- Identify member problems, member education needs, and/or trends
- Reports this information to G&A leadership and provides recommended resolution based on the analysis of data
- Research new and/or emerging regulatory guidelines, standards, business change, etc
- Affecting the member advocacy and/or grievance and appeals process
- Research Medicaid and Medicare fair hearing for appeal determinations and obtain additional information, if needed
- Analyze Medicaid and Medicare fair hearing for appeal determinations documentation and decide on how to proceed to provide a case reevaluation
- Create documentation supporting the determination including letters and Position Statements
Claim Processor
Delta Dental of California
Rancho Cordova
01.2008 - 01.2017
- Review and adjudicate dental claims utilizing personal computer terminals in accordance with company and or regulatory guidelines
- Route claims based on edit messages/EX codes, to the appropriate departments based on company and or regulatory guidelines
- Prepare formal written refund requests, status inquiries and claim amendments
- Process incoming payments, credit accounts, and prepare accounts for the recoupment process
- Identify and report system processing inaccuracy
Contact Center, Customer Service Representative
Delta Dental of California
Rancho Cordova
01.2003 - 01.2008
- Primary point of contact (telephone or written inquiries) dental professionals, groups, subscribers and brokers
- Communicates claim processing procedures and policies, group benefits and eligibility
- Deliver exceptional customer service by providing accurate information on eligibility, benefits, and claims, with a focus on customer
- Responds to telephone and written inquiries from dental professionals, groups, subscribers, and brokers, while accurately documenting information
- Skilled in communicating complex policies and procedures to customers both verbally and in writing
Education
High School Diploma -
Visions and Education
Sacramento, CA01.2002
Skills
Affordable Care Act compliance
Leadership and management
Healthcare administration
Microsoft Office proficiency
Data analysis and reporting
Root cause analysis
Multi-tasking capabilities
Organizational skills
Mentorship and development
Cross-functional collaboration
Communication skills
Process improvement strategies
State healthcare regulations
Adaptability and process design
Customer value and experience
Certification
- Situational Leadership
- Excel
- Conference Call Etiquette
- Email Etiquette
- Dealing with Difficult People
- Part C Organization Determination Appeals & Grievances
- Part D Coverage Determinations, Appeals & Grievances
- Time Management
Timeline
Quality Assurance Analyst
Delta Dental of California
01.2022 - Current
Senior Grievance and Appeals Coordinator
Delta Dental of California
01.2021 - 01.2022
Grievance and Appeals Specialist
Delta Dental of California
01.2017 - 01.2021
Claim Processor
Delta Dental of California
01.2008 - 01.2017
Contact Center, Customer Service Representative
Delta Dental of California
01.2003 - 01.2008
High School Diploma -
Visions and Education
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