CHELSEA RAMIREZ
San Tan Valley,AZ
Summary
Detail-oriented professional in appeals management with expertise in timely and compliant resolution. Coordinates effectively with internal teams and external vendors to address appeal issues and report trends to leadership. Complies with regulatory deadlines while ensuring accurate data entry and documentation across multiple systems.
Overview
8
8
years of professional experience
3
3
years of post-secondary education
Work History
Utilization Management Appeals Liaison
Oscar Health
03.2019 - Current
- Manage the receipt, investigation, and resolution of appeals in a timely, compliant, and highly effective manner
- Investigated escalated appeal requests referred by Provider Success Associatesand Claims Account Services Managers, ensuring thorough review and resolution within regulatory and compliance guidelines.
- Performed quality checks on cases to identify errors or omissions and took corrective action for appeal submissions.
- Coordinates with internal departments and external vendors relative to the investigation, review, and resolution of an appeal and the research needed to prepare the case for internal or external review.
- Cultivated relationships with internal and external stakeholders, including customers, vendors, and regulatory bodies, enhancing compliance with industry standards and regulations.
- Maintained in-depth knowledge of authorization process/workflows, staying up-to-date with changes in policies and procedures, and sharing knowledge with team members to improve overall efficiency and quality.
- Utilized systems such as Lighthouse, Jira, Rosco, Appian, Cortex, Verint and Confluence to process and track authorizations and appeals effectively.
- Retrieve assigned cases from queue and based on analysis of issues determine appropriate classification
- Supported communication with regulatory agencies concerning external appeal and dispute resolution requests.
- Collaborate with internal stakeholders to ensure IRO’s are submitted and pulled in the turnaround time requested.
- Utilize SOP’s regarding workflow to ensure high quality performance.
PROVIDER CONTRACTING
Oscar Health
01.2019 - 03.2019
- Customized contracts to align with specific provider needs, ensuring mutual satisfaction with terms and conditions.
- Established and maintained relationships with providers through effective communication and rapport-building, enhancing satisfaction and fostering repeat business.
- Completed day-to-day duties accurately and efficiently.
- Contributed innovative ideas and solutions to enhance team performance and outcomes.
- Worked successfully with a diverse group of coworkers to accomplish goals and address issues related to our products and services.
INSIDE SALES
Oscar Health
07.2018 - 01.2019
- Analyzed consumers' needs and preferences to identify plans best fitting their requirements, enhancing customer satisfaction and retention.
- Explained Oscar's offerings and product expectations, clarifying the company's value proposition and strengthening customer loyalty.
- Scheduled follow-up appointments with potential customers to address needs and provide additional information about Oscar's products and services, fostering engagement.
- Answered inbound calls and directed current members to the appropriate department, resulting in a high level of customer satisfaction and reduced call wait times.
Education
HIGH SCHOOL DIPLOMA -
Mcclinock High School
Tempe, AZ 08.2011 - 01.2015
Skills
- Claims Management
- Healthcare Software
- Operational Efficiency
- Workflow optimization
- Process improvement
- Data Analysis
- Problem-Solving
- Training and Development
- Coaching and mentoring
- Team Management
- Customer Experience
- Attention to Detail
- Adaptability
- Strong Communication
Timeline
Utilization Management Appeals Liaison
Oscar Health
03.2019 - Current
PROVIDER CONTRACTING
Oscar Health
01.2019 - 03.2019
INSIDE SALES
Oscar Health
07.2018 - 01.2019
HIGH SCHOOL DIPLOMA -
Mcclinock High School
08.2011 - 01.2015