Ashley Casarez
Huntington Park,CA
Summary
Dynamic Appeals and Grievances Specialist II at L.A. Care Health Plan with expertise in data analysis and conflict resolution. Proven track record in enhancing service delivery and compliance through effective auditing and process improvements. Adept at collaborating with interdisciplinary teams to drive operational excellence and achieve organizational goals.
Overview
11
11
years of professional experience
Work History
Appeals and Grievances Specialist II
L.A. Care Health Plan
Los Angeles, California
01.2024 - Current
- Facilitated member enrollment and eligibility verification processes.
- Managed documentation for compliance with health regulations.
- Collaborated with interdisciplinary teams to improve service delivery.
- Identifies, investigates, and resolves administrative complaints, complex provider appeals and State Fair Hearing adhering to CMS, DHCS, DMHC, MRMIB and NCQA standards and regulations.
- Participates in internal and external oversight activities, inter-rater reliability reviews and focused audits. Recommends opportunities for improvement.
- Prepare and analyze monthly appeal and grievance reports to meet internal and external reporting requirements.
Customer Solution Center Lead
L.A. Care Health Plan
Los Angeles, California
06.2020 - 01.2024
- Supervised daily operations of healthcare center, ensuring compliance with policies.
- Experienced in leading audits of complex cases to ensure regulatory and policy compliance.
- Overseeing audit workflows and collaborating cross-functionally with operational teams.
- Driving corrective actions and preparing for internal and external audits within the call center, and appeals and grievances.
- Trained and mentored staff to enhance service quality and teamwork.
- Implemented process improvements to streamline workflows within the center.
- Conducted performance evaluations to support employee development and accountability.
- Prepared reports detailing various aspects of the center's operations such as financials and staffing levels.
- Monitored customer service levels, resolving complaints promptly and professionally.
- Evaluated employee performance through one-on-one meetings and annual reviews.
- Supervised staff of up to 10 employees, providing guidance and direction to ensure efficient operations.
- Complied with company policies, objectives and communication goals.
- Monitored employee attendance, addressing any punctuality or absenteeism issues.
- Prepared detailed audit reports outlining findings and recommendations.
TELESALES
Alignment Healthcare
Orange, California
10.2017 - 06.2018
- Assist with retention of members.
- Meeting daily and monthly sales quotas.
- Assisting members with issues, inquiries or concerns.
- Establishing communication with providers and medical groups.
- Proficient in Salesforce, EZ - Member, EZ-Cap and CRM
DATA SPECIALIST - PROVIDER DISPUTE RESOLUTION
MOLINA HEALTHCARE
Long Beach, California
02.2017 - 09.2017
- Acknowledged and audited provider disputes within 15 business days of receipt.
- Researched and documented provider disputes in a professional and timely manner.
- Reviewed CMS-1500 and UB claim forms for any claim corrections from providers.
- Closed front-end disputes if no further auditing was needed.
- Reviewing DOFR and providing training, I assisted colleagues on acknowledgment, denials, database, and claims process.
MEMBER SERVICE REPRESENTATIVE III
MOLINA HEALTHCARE
Long Beach, California
11.2014 - 02.2017
- Exemplify stellar service to members and providers.
- Assist with special projects that are assigned and completed in a timely manner.
- MMP duals/Medicare member services for various states.
- Assist with provider and member claims inquiries.
- Resolve problems by clarifying issues, researching and locating alternative solutions.
- Implementing solutions and escalating unresolved problems.
- Renewals for members of Medicaid through various states.
- Renewals of Covered California members.
Education
Bachelor of Arts - Health Care Administration
University of Phoenix
Tempe, AZ06-2022
Skills
- Data analysis and reporting
- Adaptability and multitasking
- Policy interpretation and auditing
- Conflict resolution strategies
- Quality assurance processes
- Analytical problem solving
- Time management skills
- Auditing coordination and processes
Languages
Spanish
Professional
English
Professional
Timeline
Appeals and Grievances Specialist II
L.A. Care Health Plan
01.2024 - Current
Customer Solution Center Lead
L.A. Care Health Plan
06.2020 - 01.2024
TELESALES
Alignment Healthcare
10.2017 - 06.2018
DATA SPECIALIST - PROVIDER DISPUTE RESOLUTION
MOLINA HEALTHCARE
02.2017 - 09.2017
MEMBER SERVICE REPRESENTATIVE III
MOLINA HEALTHCARE
11.2014 - 02.2017
Bachelor of Arts - Health Care Administration
University of Phoenix
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