Deborah Schoonover-Chai
Huntington Beach,CA
Summary
Credentialing and Quality Improvement professional with expertise in managing and streamlining credentialing processes. Strong focus on compliance, accuracy, and timely completion of credentialing tasks. Compassionate and driven professional passionate about maximizing patient care standards. Effective in team collaboration, known for adaptability and reliability. Proficient in database management, policy implementation, quality improvement and regulatory compliance. Highly accurate, productive and goal-driven with excellent skills in verbal and written communication, decision making and resource coordination.
Overview
19
19
years of professional experience
Work History
Ntwrk Mgmt Provider Relations, Sr. Provider Ops.
UnitedHealthcare
04.2023 - Current
- Managing provider networks that support client base. This includes hospital, physician, dental, and pharmaceutical networks. Such as but not limited to provider relations, analyzing provider performance, creating provider reimbursement arrangements, and credentialing.
- Accountable for the full range of provider relations and service interactions within UnitedHealthGroup via Live Person Chat.
- Working on end-to-end provider claim and call quality.
- Ease of use of physician portal and future service enhancements.
- Training & development of external provider education programs.
- Designs and implements programs to build and nurture positive relationships between the health plan, providers (physician, hospital, ancillary, etc.), and practice managers.
- Directs and implements strategies relating to the development and management of a provider network.
- Identifies gaps in network composition and services to assist the network contracting and development staff in prioritizing contracting needs.
- Extensive work experience within own function.
- Strong Communication within department and business partners.
- Demonstrates great depth of knowledge/skills in own function.
- Applies knowledge/skills to a range of moderately complex activities.
- Maintaining quality and accuracy.
- Works independently.
- Act as a resource for others.
- Proactively identifies solutions to non-standard requests.
- Work assigned projects given by Management.
- Plans, prioritizes, organizes and completes work to meet established objectives.
Medicare & Retirement Appeals & Grievance Coord.
UnitedHealthcare
04.2019 - 04.2023
- Providing expertise or general support to teams in reviewing, researching, investigating, negotiating and resolving all aspects of appeals and grievances.
- Communicates with appropriate parties regarding appeals and grievance issues, implications and decisions.
- Analyzes and identifies trends for all appeals and grievances.
- May research and resolve written Department of Insurance (DOI) complaints and complex or multi-issue provider complaints submitted by consumers.
- Identify and obtain additional information needed to make an appropriate determination.
- Ensure that members obtain a full and fair review of their appeal or grievance.
- · Manage case load, closing 5+ cases per week.
- Assisted with day-to-day operations, working efficiently and productively with all team members.
- Passionate about learning and committed to continual improvement.
- Managed time efficiently in order to complete all tasks within deadlines.
- Demonstrated strong organizational and time management skills while managing multiple projects.
- Strong Communication within department and Business Partners.
- Demonstrates great depth of knowledge/skills in own function.
- Maintaining quality and accuracy.
- May act as a resource for others.
- Resource for new teams working Grievances. Answering all questions/concerns they might have regarding their cases.
- Letter Reviews – Reviewed letters written to ensure cases were being worked accordingly and accurately.
- Letter Review for CMS Audit project.
Population Health Management HealthCare Advisor
Optum, UnitedHealth Group
03.2018 - 04.2019
- Navigate through multiple platforms and databases to retrieve information regarding medical plans, prescription plans, flexible spending accounts, health reimbursement accounts, vision plans, dental plans, employer-based reward plans, claims submissions, clinical programs, etc., for member inquiries.
- Remain current on all communicated changes in process and policy guidelines. Adapt to all process changes quickly and maintain knowledge of changes at site level and entity level by utilizing all available resources.
- Perform multiple types of claims adjustments, including closed claims, denied claims and simple adjustments (both offline, and real-time on calls.)
- Own issues through to resolution on behalf of the customer in real time or through comprehensive and timely follow-up with the member and/or Health Advisor or Benefit Advocate.
- Research complex issues across multiple databases and work with support resources to resolve customer issues and/or partner with others to resolve escalated issues.
- Work directly with site leadership to remove process barriers.
Provider Network Credentialing Team Lead
OptumServe
01.2017 - 03.2018
- Led Credentialing team members in daily tasks.
- Responsible for work distribution to Credentialing Specialist on credentialing and re-credentialing applications for providers and facilities.
- Maintain department workload status reports.
- Communicates provider credentialing status internally and externally when necessary.
- Maintain knowledge of current credentialing requirements, recognizing the latest standards and procedures.
- Devised and implemented processes and procedures to streamline operations.
- Generated reports detailing findings and recommendations.
- Maintained database systems to track and analyze operational data.
- Assist department staff with questions.
- Performed quality review to ensure department meets company quality standards.
- Performs new team member training.
- Collected performance data and generates reports for both individual and team performance.
- Worked closely with Credentialing Supervisor to delegate tasks and goals.
- Completed projects as assigned by Senior Leadership.
- Trained new team members by relaying information on company procedures and safety requirements.
- Coached team members in techniques necessary to complete job tasks.
- Promoted a positive work environment by fostering teamwork, open communication, and employee recognition initiatives.
- Served as a role model for the team by demonstrating commitment to excellence, professionalism, and adherence to company values at all times.
Medical Staff Quality Peer Review/Credentialing Coordinator
St. Francis Medical Center
05.2013 - 01.2017
- Completed data collection and analysis for Medical Record review. This included but limited to, re-admissions
- Reviewed and determined quality of care patient received by their Provider/Hospital.
- Presented written summarized case review on findings to Department Committee Chair as well as Hospital Committee to determine case outcome and leveling score.
- Completed initial credentialing appointments, re-appointments, proctoring, temporary privileges, competencies, and monthly monitoring of expired medical licenses and malpractice insurance documents.
- Integrated Quality Improvement information and action from Medical Staff department reviews and hospital committees to maintain current physician profile data, outpatient core measures, critical values, Performance Improvement data entry, Performance Improvement reports, incident reports, patient satisfaction data reports, and direct observation throughout hospital for data collection.
- Maintained knowledge of current credentialing requirements recognizing the latest standards and procedures.
- Reviewed MD profiles for Ongoing Professional Practice Evaluation (OPPE) pertaining to provider credentialing.
Enrollment & Eligibility Representative
OptumRx
05.2012 - 05.2013
- Process and troubleshoot batch eligibility files to verify distribution of all necessary outbound reports.
- Coordinate eligibility set-up for new clients.
- Prepare, process, and maintain new member and group enrollments.
- Respond to member eligibility regarding group questions and verify enrollment status.
- Reconcile eligibility discrepancies. Analyze transactional data and submit retroactive eligibility changes.
- Liaison for Client Management and Development teams.
- Adhere to all key audit controls and comply with all established standards associated with HIPAA, SOX, and SAS70.
Quality Management Peer Review Triage Analyst
Western Medical Center
10.2007 - 05.2012
- Performed data collection and analysis for Medical Record review.
- Determined Quality of Care patient received brought forth by patient Appeals and Grievances.
- Performed case reviews/peer review summary on patient grievances.
- Case Presentation to Department Committee Chair/Hospital Committee to determine case outcome and scoring.
- Integrated Quality Improvement information and action from Medical Staff department reviews and hospital committees to maintain current physician profile data, outpatient core measures, critical values, Performance Improvement data entry, Performance Improvement reports, incident reports, patient satisfaction data reports, and direct observation throughout hospital for data collection.
- MD profiles for Ongoing Professional Practice Evaluation (OPPE) pertaining to provider credentialing.
Quality Management Peer Review Triage Analyst
UnitedHealthcare
12.2005 - 10.2007
- Reviewed appeals and grievances, determining the Quality of Care the member received by their Physician, Medical Group, and/or Hospital.
- Obtained supporting documents for case review/peer review.
- Reviewed supporting case documents.
- Rendered decision for non-clinical complaints, appeal and grievances by scoring providers using Levels 1, 2, and 3 using sound, fact-based decision making.
- Provided written documentation to Medical Director for final review.
- Communicated final outcome with members and physicians/providers within the TAT for responses and closed cases.
- Provided Team Lead assistance to the Clinical Information Associates when needed.
Education
No Degree - General Studies
Goldenwest Community College
Huntington Beach, CAHigh School Diploma -
Tracy High School
Cerritos, CA04.1994
Skills
- Healthcare Industry Knowledge
- Medicare and Medicaid knowledge
- Compliance Management
- Strong interpersonal skills
- Teamwork and Collaboration
- Problem-Solving
- Time Management
- Excellent Communication
- Organizational Skills
- Active Listening
- Task Prioritization
- Self Motivation
- Quality Assurance
- Process Improvement
- Regulatory Compliance
- Issue Research
Timeline
Ntwrk Mgmt Provider Relations, Sr. Provider Ops.
UnitedHealthcare
04.2023 - Current
Medicare & Retirement Appeals & Grievance Coord.
UnitedHealthcare
04.2019 - 04.2023
Population Health Management HealthCare Advisor
Optum, UnitedHealth Group
03.2018 - 04.2019
Provider Network Credentialing Team Lead
OptumServe
01.2017 - 03.2018
Medical Staff Quality Peer Review/Credentialing Coordinator
St. Francis Medical Center
05.2013 - 01.2017
Enrollment & Eligibility Representative
OptumRx
05.2012 - 05.2013
Quality Management Peer Review Triage Analyst
Western Medical Center
10.2007 - 05.2012
Quality Management Peer Review Triage Analyst
UnitedHealthcare
12.2005 - 10.2007
No Degree - General Studies
Goldenwest Community College
High School Diploma -
Tracy High School
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