Elsa Dominguez
Chino Hills,CA
Summary
Dedicated healthcare professional with a history of meeting company goals utilizing consistent and organized practices. Skilled in working under pressure and adapting to new situations and challenges to best enhance the organizational brand.
Overview
25
25
years of professional experience
1
1
Certification
Work History
Manager, Care Coordination
Pomona Valley Hospital Medical Center
2023.01 - Current
- Achieved departmental goals by developing and executing strategic plans and performance metrics.
- Evaluated employee performance and conveyed constructive feedback to improve skills.
- Established team priorities, maintained schedules and monitored performance.
- Ensures staff has current Health Plan benefits guidelines for appropriate interpretation. Reviews process of plan benefits function to search CPT, HCPS, and ICD10 codes to determine coverage.
- Develops resource tools and conducts training to educate the clinical and administrative staff in the many aspects of clinical, delegated functions and polices/procedures at least annually to ensure staff understanding.
- Optimized resource allocation by conducting regular performance evaluations and providing personalized coaching for staff development.
- Enhanced customer satisfaction by resolving disputes promptly, maintaining open lines of communication, and ensuring high-quality service delivery.
- Facilitated successful cross-functional collaborations for the completion of key projects, fostering strong working relationships among team members.
Supervisor, Transitional Care and Benefits & Elig.
Inter Valley Health Plan, Non-profit HMO
2019.05 - 2022.12
- Measured effectiveness of customer success by defining operational metrics, tracking systems and reporting to executive team.
- Evaluated employee performance and coached and trained to improve weak areas.
- Utilized standard operating procedures, effective crew resource management, communication and procedures specified in company operation manual.
- Provided supportive link between external customers and internal operations.
- Worked with management team to implement proper division of responsibilities.
- Maintained compliance with company policies, objectives and communication goals.
- Responsible for managing health services provider appeals to make sure that all pertinent information was available for Medical Director review within the allotted timeframe.
- Managed and prepared files for case submission to Maximus Federal.
- Effective communication with internal and external team to assist with benefit interpretation and provide accurate Medicare guidelines.
- Managed transition of care for post hospital discharges.
Transitional Care Coordinator
Inter Valley Health Plan, Non-profit HMO
2015.08 - 2019.05
- Communicated with patients, ensuring that medical information was kept private.
- Implemented successful healthcare program through professionalism, quality of care, medical teaching and patient satisfaction.
- Monitored and inspected staff processes to eliminate hazards posed for both residents and staff while ensuring continuous compliance with regulations.
- Assisted with answering phones for Benefits & Eligibility Department (50) calls per day.
- Reviewed daily claims submission for DME and Home Health.
- Improved patient satisfaction scores with timely coordination of resources, including home care and rehabilitation services.
- Enhanced patient care by coordinating transitional services and ensuring seamless communication between healthcare providers.
Personal Care Advocate
Inter Valley Health Plan, Non-profit HMO
2011.01 - 2015.08
- Assisted in completing and maintaining care management during and after patient's hospitalization.
- Researched issues and took appropriate action to resolve issues within turnaround time requirements and quality standards.
- Prepared documents and reports for clinical reviews and discharge plans.
- Documented activities and progress in electronic medical record per defined policy and procedures.
- Worked with enrollees to identify gaps in care or obstacles to care.
- Entered timely and accurate data into electronic medical records to communicate member needs.
- Conducted patient assessments to determine appropriate levels of care.
- Contacted third-party payors to obtain and confirm authorization for services and communicated necessary related clinical information.
- Facilitated communication between patients and various departments and staff.
- Applied administrative knowledge and courtesy to explain procedures and services to patients.
- Helped address client complaints through timely corrective actions and appropriate referrals.
- Worked with patients to ascertain issues and make referrals to appropriate specialists.
- Recommended service improvements to minimize recurring patient issues and complaints.
- Organized patient records and database to facilitate information storage and retrieval.
- Maintained provider appeals for claims review, 30 per month, to meet Medicare deadlines for timely submissions.
Benefits and Eligibility Coordinator
Inter Valley Health Plan, Non-profit HMO
2006.11 - 2011.01
- Monitored and entered daily face sheets notification for hospital admissions.
- Entered daily referrals for managed shared risk providers.
- Answered calls within 30 second timeframe to meet industry standards.
- Improved provider satisfaction by efficiently managing eligibility cases and providing timely updates.
- Trained new Eligibility Coordinators on department procedures, contributing to the overall improvement of the team''s performance.
- Managed caseloads effectively through regular follow-ups and prompt communication with clients, ensuring their needs were met throughout the process.
- Resolved discrepancies with provider applications to verify eligibility.
- Responsible for all incoming faxes and emails to make sure they are all documented on excel for monitoring.
- Knowledge of ICD, CPT and HCPS.
Referral Specialist
Chino Medical Group
1999.03 - 2006.11
- Verified insurance benefits and eligibility for specialty procedures before referring clients.
- Scheduled appointments with specialists on behalf of clients.
- Worked with Surgery Coordinator to obtain prior authorization Surgical procedures.
- Built professional relationships with service providers.
- Assisted clients in locating resources that accepted various insurances.
- Notified and reminded clients of appointments.
- Coordinated with medical staff and patients to find cost-effective options for services.
- Weighed patient need, provider availability and insurance coverage to determine optimal scheduling.
- Called insurance companies to get precertification and other benefits information on behalf of patients.
- Completed up to 40 referral requests each day for medical services.
- Answered telephone calls to offer office information, answer questions and direct calls to staff.
- Received, recorded and addressed incoming and outgoing communication via telephone and email.
- Organized and maintained patient chart filing system to promote quick data finding for staff.
- Coordinated referrals through insurance and other medical specialists and documented details in patient charts.
Education
None - Criminology
Everest College - Ontario
Ontario, CA08.2000
Skills
- Team Building
- Decision-Making
- Flexible and Adaptable
- Multitasking Abilities
- Excellent Communication
- Interpersonal Communication
- Problem-Solving
- Organization and Time Management
- Analytical and Critical Thinking
- Data Analytics
Certification
- HIPPA Compliance
- Fraud and Abuse Awareness
- Compliance Program
- Part D Coverage Determinations, Appeals, and Grievances-CMS
- Part C Organization Determinations, Appeals, and Grievances- CMS
- Quality Communication with A.I.D.E.T.
- Health Equity Diversity and Inclusion
- Social Determinants of Health
- Implicit Bias
- LGBTQ+
- Cultural Linguistic
Timeline
Manager, Care Coordination
Pomona Valley Hospital Medical Center
2023.01 - Current
Supervisor, Transitional Care and Benefits & Elig.
Inter Valley Health Plan, Non-profit HMO
2019.05 - 2022.12
Transitional Care Coordinator
Inter Valley Health Plan, Non-profit HMO
2015.08 - 2019.05
Personal Care Advocate
Inter Valley Health Plan, Non-profit HMO
2011.01 - 2015.08
Benefits and Eligibility Coordinator
Inter Valley Health Plan, Non-profit HMO
2006.11 - 2011.01
Referral Specialist
Chino Medical Group
1999.03 - 2006.11
None - Criminology
Everest College - Ontario
- HIPPA Compliance
- Fraud and Abuse Awareness
- Compliance Program
- Part D Coverage Determinations, Appeals, and Grievances-CMS
- Part C Organization Determinations, Appeals, and Grievances- CMS
- Quality Communication with A.I.D.E.T.
- Health Equity Diversity and Inclusion
- Social Determinants of Health
- Implicit Bias
- LGBTQ+
- Cultural Linguistic
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