Grace GONZALES
Corpus Christi
Summary
Detail-oriented professional skilled in appeals processing and compliance with health regulations. Proven ability to streamline procedures and enhance client communication. Ready to contribute to improved operational efficiency.
Overview
36
36
years of professional experience
Work History
Member Appeals Coordinator
Driscoll Health Plan UM Department
Corpus Christi
09.2024 - Current
- Facilitated the appeals process for members within the health plan system.
- Reviewed and analyzed appeal requests for compliance with health regulations.
- Coordinated communication between members and healthcare providers for resolution.
- Maintained accurate records of appeals and outcomes in the database system.
- Collaborated with team members to streamline appeal procedures and documentation.
- Maintained records of all appeal activities in a timely manner.
- Tracked progress of ongoing appeals cases using computer software systems.
- Collaborated with physicians, nurses, administrators, and other staff members to resolve issues quickly and efficiently.
- Answered incoming calls from providers seeking assistance with appeals processing.
- Provided support to internal personnel regarding appeals process inquiries.
- Compiled and documented information for appeal cases.
- Retained strong medical terminology understanding in effort to better comprehend procedures.
Member Appeals Coordinator
Driscoll Health Plan QM Department
Corpus Christi
06.2009 - 08.2024
- Facilitated appeals process for health plan members, ensuring compliance with regulations.
- Reviewed and analyzed appeal requests to uphold health standards.
- Maintained accurate records of appeals and outcomes within database system.
- Collaborated with team members to optimize appeal procedures and documentation.
- Oversaw transmissions between offices while maintaining case files.
- Answered incoming calls from providers regarding appeals processing assistance.
- Provided timely support to internal personnel for appeals inquiries.
- Compiled and documented essential information for appeal cases.
Pre Certification Nurse
Corpus Christi Medical Center Bay Area
Corpus Christi
01.2008 - 05.2009
- Maintained accurate patient records using electronic health record systems.
- Secure Hospital Authorizations for payment for all lines of business.
- Coordination of benefits for all patients being admitted to facility.
- Referred case to financial counselors when assistant needed.
- Worked closely with admitting staff, OR staff, and Physician offices.
- Maintain upmost level of confidentiality at all times.
Case Manager Coordinator
Corpus Christi Medical Center Bay Area
Corpus Christi
02.1996 - 12.2007
- Managed case documentation and maintained accurate records.
- Coordinated client assessments and developed personalized service plans.
- Provided training and guidance to new case management staff members.
- Provided crisis intervention services when needed.
- Attended workshops and seminars related to case management practices.
- Collaborated with healthcare professionals to ensure continuity of care for clients.
- Monitored client progress towards goals set by case managers or social workers.
- Organized transportation for clients who lacked access to public transportation or private vehicles.
- Assigned cases to employees, prioritizing tasks to meet upcoming deadlines.
- Assisted with the coordination of care between providers, families, and other community resources.
- Developed and implemented case management plans for clients to ensure their needs were met.
- Acted as a liaison between multiple agencies providing assistance to clients.
- Participated in interdisciplinary team meetings with medical staff, social workers and other relevant personnel.
- Maintained accurate documentation of all activities related to client cases.
- Adhered to ethical principles and standards to protect clients' confidential information.
- Maintained logs and electronic client records following department and agency policies for effective monitoring.
- Maintained confidentiality and adhered to professional ethics and standards.
- Utilized case management software and databases for efficient information tracking.
- Prepared and presented case reports and summaries to stakeholders and management.
- Provided referrals to appropriate medical, mental health, and social services.
Service Assurance Manager
Humana
Corpus Christi
02.1990 - 01.1996
- Led audit teams to evaluate compliance with healthcare regulations.
- Facilitated training sessions on assurance best practices for staff.
- Provided guidance on risk management frameworks to senior leadership.
- Conducted quarterly internal audits in collaboration with management.
- Prepared management reports detailing key audit findings and recommendations.
- Reviewed audit reports for accuracy and completeness.
- Assisted in formulating corrective action plans for identified deficiencies.
- Developed internal control systems, processes, and procedures to enhance compliance.
Education
Associate of Health Information Technology -
Del Mar College
Corpus Christi, TX12-2018
License Vocational Nursing - Nursing
Del Mar College
Corpus Christi, TX05-1978
Skills
- Appeals processing
- Health regulations
- Database management
- Medical terminology
- Case tracking
- Client communication
- Confidentiality
- Organizational skills
- Time management
- Attention to detail
- Problem solving
- Critical thinking
- Multitasking
Timeline
Member Appeals Coordinator
Driscoll Health Plan UM Department
09.2024 - Current
Member Appeals Coordinator
Driscoll Health Plan QM Department
06.2009 - 08.2024
Pre Certification Nurse
Corpus Christi Medical Center Bay Area
01.2008 - 05.2009
Case Manager Coordinator
Corpus Christi Medical Center Bay Area
02.1996 - 12.2007
Service Assurance Manager
Humana
02.1990 - 01.1996
Associate of Health Information Technology -
Del Mar College
License Vocational Nursing - Nursing
Del Mar College