Carlos Soto
Davenport,FL
Summary
Experienced at navigating complex federal healthcare systems, interpreting policies, and providing customers accurate information while ensuring full regulatory compliance of information management. Possess exemplary interpersonal skills; adept at working across department and organizational lines to build open dialogue and facilitate collaboration between program / project stakeholders. Tenacious problem-solver committed to providing stellar customer service, tackling challenging projects, and mastering new processes to achieve organizational goals. Solid database, spreadsheet, Internet, and productivity software proficiencies; skilled in MS Office Suite (Access, Excel, Outlook, PowerPoint, Word), E-Paces, McKesson.
Overview
19
19
years of professional experience
1
1
year of post-secondary education
Work History
Appeals and Grievances Coordinator
Healthfirst
3 2009 - Current
- Conducted comprehensive investigations on complex cases, leading to successful outcomes and satisfied clients.
- Reduced grievances and arbitration needs by educating frontline managers on techniques for enhancing interactions between labor and leadership.
- Ensured timely submission of required reports to regulatory agencies by diligently monitoring deadlines and maintaining accurate records.
- Drove continuous improvement initiatives within team, fostering culture of excellence and consistently exceeding client expectations.
- Established positive relationships with internal departments, enhancing cooperation when resolving cross-functional grievances.
- Implemented feedback loop mechanisms to ensure continuous improvement of grievance management process, leading to more effective resolution system.
- Actively participated in weekly Integra partner meetings, providing thorough follow-up and constructive feedback. I proactively engaged in DSE SharePoint, facilitating effective communication and follow-ups.
- Outreach to doctors for RX and clinicals, collaboration with Utilization Management Department for authorization updates and revisions, and coordination with durable medical equipment providers and personal care providers to ensure service status.
- Actively worked on special projects, contributed to creation of job aids, and played crucial role in audit readiness, including DFS audits, leveraging my attention to detail and organizational skills to contribute to seamless audit process.
- Prior to promotion, worked in Care Management Dept as Health Care Coordinator in where my duties included but not limited to carrying assigned case load of 100 team members who require long term care coordination and health navigation.
- Create authorizations for services were approved and applicable.
- Worked within interdisciplinary care team to support timely communication of member issues or needs and monitors screening of members effectively to improve quality and cost outcomes.
Patient Advocate
Wyckoff Heights Hospital
05.2005 - 05.2006
- Prepare and type correspondence, reports, special studies and conducted research as necessary and forwarded them to NY State Department of Health
- Consulted with appropriate staff as part of resolution process to ascertain and assure corrective measures are taken to resolve complaint in timely and effective manner, as well as developing acceptable resolutions; and following-up on outcomes.
- Recognized for ability to work with very diverse clients and staff and assessing what is needed, recommending sensible solutions and effectively motivating staff to implement them in spirit of collaboration.
- Effectively addressed and manage complaint spanning wide range of healthcare settings, including both inpatient hospital and outpatient satellite clinics, with case load averaging 35 patients weekly.
- Monitored patient progress throughout treatment course, advocating for adjustments when necessary to optimize outcomes
- Resolved patient billing issues in line with established guidelines
- Assisted patients in navigating complex healthcare systems and procedures to reduce emotional strain
Education
Medical Assistant, Nurse Technician and Medical Billing Certification - Medical Assisting
New York Medical Center Career Training Center
Queens, NY 01.2002 - 12.2002
Skills
Extensive knowledge of Word Processing, MS Office (Word, Excel, PowerPoint)
Medical Software proficiency, Insurance procedures, Medical Records, HIPAA regulations
Project Management Certified
Fluent in English and Spanish
Improvement plan knowledge
Service monitoring and evaluation
Analytical Thinking
Idea Development and Brainstorming
Team Collaboration
Adaptability and Flexibility
Timeline
Patient Advocate
Wyckoff Heights Hospital
05.2005 - 05.2006
Medical Assistant, Nurse Technician and Medical Billing Certification - Medical Assisting
New York Medical Center Career Training Center
01.2002 - 12.2002
Appeals and Grievances Coordinator
Healthfirst
3 2009 - Current