Ciara Walter

• Support implementation and optimization of various operational processes and systems.
• Assist monitoring of operational processes and procedures
• Develop and test new tools, reports, and technologies
• Work with existing software and programs to capture, validate, contextualize, and share findings.
• Performed quality assurance on systems to confirm optimal performance.

• Work with cross-functional teams to identify and resolve issues.
• Complete UAT and SIT testing as required in cloud software system.
• Assist management by gathering information from wide variety of sources

• Lead team of 15 provider appeals coordinators.
• Streamlined operations and prioritized tasks, allowing coordinators to get ahead on backlog of cases.
• Prepare staff performance reviews.
• Manage special projects.
• Evaluate department processes and make recommendations to improve operational performance.
• Monitor inventory of complaints, grievances, and appeals.
• Continually examine team performance against department standards

In addition to the Provider Appeals Coordinator, the Provider Appeals Coordinator II has additional responsibilities of:

• Mentor new hire staff throughout onboarding.
• Distribute case workload to Provider Appeal Coordinators.
• Monitor management reports including but not limited to timeliness, case volumes, overturns and identify opportunities for improvement.
• Support implementation of special projects.
• Organized and managed appeals caseloads, prioritizing high-priority cases for timely resolution.
• Developed strategic action plans to address identified issues, leading to reduction in appeals backlog.

• Investigate member complaints and grievances, and provider appeals, and respond in writing according to department standards
• Effectively utilize key internal and external Health Plan contacts, including: Health Plan staff, providers, and external review organizations, to help in this process.
• Organize all tasks within regulatory requirements/deadlines.
• Understand and interpret medical information, recognize trends, and identify opportunities for improvement within Health Plan.
• Organized and managed appeals caseloads, prioritizing high-priority cases for timely resolution.

• Interview and register patients at time of or prior to visit date
• Confirm/verifies insurance benefits with appropriate carrier via online verification systems or telephone inquiries
• Schedules appointments based on business unit requirements
• Collects and records patient payment including coinsurance, copayment & deductibles
• Provided exceptional customer service to build strong relationships with patients, leading to increased loyalty and return visits.
• Improved patient satisfaction by efficiently managing appointment scheduling and coordinating follow-up care.
• Used Epic to schedule appointments.

• Please see job description above under same role

• Conduct case intake process, via cases received through verbal and written requests, and set up new cases in C&G information system
• Accurately and promptly assess, enter and maintain documents in files and/or databases to assure that information is organized and readily available.
• Identify and escalate priority and expedited issues to management within timely manner.
• Complete data entry into various information systems to support C&G processes
• Maintained strict confidentiality of patient information, adhering to HIPAA guidelines and company policies.

• Developed strong product knowledge to provide informed recommendations based on individual customer needs.
• Aided members, providers, prospective members and others, both internal and external, with information concerning benefits, coverage, procedures, etc.
• Worked with care management staff, and other staff as appropriate, to develop necessary materials; special projects; member/provider alerts; and ability to discuss new procedures with members and providers
• Managed high-stress situations effectively, maintaining professionalism under pressure while resolving disputes or conflicts.
• Responded to customer requests, offering excellent support and tailored recommendations to address needs.
• Developed highly empathetic client relationships and earned reputation for exceeding service standard goals.