April Brown
Los Angeles,CA
Summary
I am a very energetic and passionate individual with demonstrated problem solving and issue resolution skills. I am eager to work and currently pursuing my Bachelor's degree in Human Services. I am accustomed to a fast pace environment and adapt to change easily. I possess a strong learning agility and am a strong individual contributor, as well as an effective team player, striving to be a key contributor at every opportunity.
Overview
9
9
years of professional experience
Work History
Grievance Coordinator
Scan Health Plan
09.2018 - Current
- Analyze and resolved verbal and written formal grievances from members
- Identify irregular trends with grievances, and other areas as appropriate to identify root causes and appropriate steps for resolution
- Research issues utilizing systems ad clinical assessment skill, knowledge and approved "Decision Support Tools" in decision making processes regarding health care services and care provided to members.
- Supports pay-for-performance programs, including data entry, tracking, organizing, and researching information
- Manage time efficiently in order to complete all tasks within deadlines.
Appeals Coordinator
Care1st Health Plan
10.2017 - 09.2018
- Worked closely with Clinical Nurse Specialist and Medical Directors to resolve member appeals and reviewed clinical information for appeals using nationally recognized criteria to determine the need for requested services and performed medical billing and adjustments for claims
- Investigated and resolved complex patient and insurance provider complaints related to enrollment and claims, provider payment disputes, medical appeals, and reversals within the health care industry
- Responded to member, provider, and client telephone inquiries regarding status, processed appeals
Appeals and Grievance Specialist
Molina Healthcare
04.2016 - 10.2017
- Responsible for submission, intervention and resolution of appeals, grievances, and/or complaints from Molina members and related outside agencies
- Researched issues utilizing systems and clinical assessment skills, knowledge and approved "Decision Support Tools" in the decision-making process regarding health care services and care provided to members
- Requested and reviewed medical records, notes, and/or detailed bills as appropriate, evaluated for medical necessity and appropriate levels of care, formulated conclusions per protocol and collaborates with Medical Directors and other team members to determine response, and assured timeliness and appropriateness of responses
Contract Specialist
Molina Health Care
01.2015 - 04.2016
- Provide ongoing administrative support to the provider contracting department.
- Negotiate, Draft, Amend, and executing Primary Care Physician and Specialist contracts.
- Negotiate and finalize patient specific (MOU's) memorandum of understanding with non par providers to ensure reimbursement rates are within parameters.
- Assist with filling specialty gaps that generate cost savings while working closely with network management for assistance.
- Assist credentialing department with obtaining credentialing documents from providers and maintaining provider rosters by completing providers adds, terms, and demographic updates.
- Manage and maintain the contracting change form Inventory to ensure completion of any backlogged tasks as well as manage the provider inquiry boxes responding to daily emails.
- Act as a liaison with various internal departments to facilitate and resolve provider claims inquiries/disputes, contracts and system related issues.
Member Service Coordinator
Molina Healthcare
04.2014 - 01.2015
- Responded to Member and Provider inquiries and complaints while locating resources for problem resolution with accurate and courteous service
- Processed requests for the release of members from Health Plan contract, works directly with management, and worked closely with other Departments specifically Enrollments
- Handled escalated issues as directed by Member Services Director, complied with workplace privacy standard and State regulations, and verified Eligibility for Providers
Education
Bachelor’s - Human Services
California State University of Los Angeles
06.2024
Certification - Life Insurance
Primemerica
Carson, CA06.2022
Certification - Phlebotomy
Charter College
Long Beach01.2015
High School Diploma -
Bellflower High School
Bellflower, CA06.2001
Skills
- Proficient in Microsoft Word, Excel, Outlook, and PowerPoint
- Experienced with various information and database systems such as QNXT, Medhok, IKA, Cisco, EOB Systems
- Experience with guideline processing requirements for Medi-Cal, Medicare, Cal MediConnect (MMP) and Covered California (Marketplace)
- Demonstrate research and resolution skills
- Strong customer service experience with focus on healthcare members and providers
Objective
To seek and maintain a full-time position that offers professional challenges utilizing interpersonal skills, excellent time management and problem-solving skills. To be part of a dynamic work environment, that will provide opportunities for professional growth and development, while I further my education and advance my career.
Timeline
Grievance Coordinator
Scan Health Plan
09.2018 - Current
Appeals Coordinator
Care1st Health Plan
10.2017 - 09.2018
Appeals and Grievance Specialist
Molina Healthcare
04.2016 - 10.2017
Contract Specialist
Molina Health Care
01.2015 - 04.2016
Member Service Coordinator
Molina Healthcare
04.2014 - 01.2015
Bachelor’s - Human Services
California State University of Los Angeles
Certification - Life Insurance
Primemerica
Certification - Phlebotomy
Charter College
High School Diploma -
Bellflower High School
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