Ismael Bustamante
Long Beach,CA
Summary
Forward-thinking team leader skilled at operating departments efficiently with 10 years of health care experience. Knowledge and expertise in the areas of PDRs, Member and Provider Appeals, Grievances, Medicare, Medicaid and Claims. Experience includes knowledge of pre-service and post service appeals, grievances, team oversight, claims, coding, Medi-Cal, D-SNP, Applicable Integrated Plans and Medicare rules and regulations. Managements style blends professionalism, capability, adaptability, and compassion with focus on strategic approaches to improve the success of the department. Credited for being reliable, dedicated and with the ability to build lasting partnerships.
Overview
13
13
years of professional experience
Work History
Manager, Appeals & Grievances
CalOptima Health
2022.03 - Current
- Manage a team of four supervisors, two Seniors, 17 resolution specialists, 12 Intake Clerks, and one reporting analyst.
- Manage the PDR, Provider Appeals, A&G Reporting and both Member and Intake teams.
- Monitoring of a high volume of PDRs, Member and Provider appeals and grievances.
- Ensure that thorough research, analysis, outreach, and follow-ups is conducted to appropriately set-up and resolve cases.
- Work closely with the Reporting Analyst to develop and implement robust reporting tools such as Tableau, CORE reports, and A&G Database reporting tools and Dashboard.
- Manage and make recommendation on development and maintenance of an effective appeals and grievance process and system consistent with the CalOptima policy to monitor PDRs, Provider Appeals and Grievances.
- Developed, implemented, maintain, and review the adequacy of the PDR and A&G systems, reporting, policies and procedures.
- Coordinate with the Director of A&G in providing trends to internal and external departments.
- Developed and maintain a close working relationship with Audit and Oversight and key departments to ensure CalOptima, Health Networks and Third Party Administrators are up to date with regulatory, departmental, and organizational changes impacting A&G processes.
- Ensure timely and effective data collection, summarization, integration and reporting of productivity, status, and trends for specific committees such as Quality Improvement Committee, A&G Committee, and other ad hoc requests.
- Continuous changes and implementations of staff and departmental performance goals.
- Developed and updated policies, procedures and standards for all A&G activities and member and provider complaints.
A&G Pre-Service Appeals Manager
Molina Healthcare
2021.11 - 2022.03
- Managing a team of 28 reports (3 Supervisor) and 25 A&G Specialists
- Monitoring of high volume of Member and Provider Appeals and for timeliness
- Responsible for QIO tracking and submission to A&G Nurses for DENC preparation and Submission to the QIO
- Monitoring timely handling of all CTMs
- Interaction with external regulatory agencies and state specific Medicaid Health Plans that may be involved with the appeals and or grievance process
- Ensure that that thorough research, analysis, outreach, and follow-ups are conducted to appropriately resolve/ set-up cases
- Establish and maintenance of internal tracking and monitoring systems
- Responsible to create, update and maintain all department related Policies and Procedures
- QA of monthly, quarterly, and yearly reports for regulatory reporting
- NCQA Monthly remediation reviews
- Direct Oversight and review of All Pre-Service and Post Service Appeals
- Establish and maintenance of internal tracking and monitoring systems
- Work with Member Services leadership for process and compliance improvements
- Ensure appropriate usage of resources to facilitate the appeals process
- Analyze data for trends and process improvement
- Responsible for hiring, mentoring, training and coaching staff, performance reviews and corrective actions plan
- Quality auditing and review data integrity, case summary packets, resolution letters and Maximus Packets before appeal closures.
A&G Intake Manager
Molina Healthcare
2021.03 - 2021.11
- Tasked with building and establishing a Medicare A&G Intake team
- Responsible for hiring, training, mentoring and coaching staff, performance reviews and corrective actions plans
- Managing a team of 13 direct reports (1 Supervisor and 12 Clerks)
- Ensuring all Grievances and Appeals are triaged to the correct area within A&G in a timely manner
- Established and maintained internal tracking and monitoring systems
- Developed, updated, and maintained Intake related desk level procedures and quick reference guides
- QA of appeals and grievance case set up by Intake Clerks to ensure accuracy
- Ensure appropriate usage of resources to facilitate the appeals and grievance case set up process
- Analyze data for trends and process improvement.
A&G Post Service Appeals Supervisor
Molina Healthcare
2020.08 - 2021.03
- Managing a team of 9 reports (1 Supervisor and 1 Lead) and 7 Appeals Specialists
- Production oversight of member and provider appeals to ensure all contractual and regulatory agreements are met
- Monitoring productivity and quality and implement appropriate actions to ensure department goals are met
- QA of Appeals to ensure accuracy of case processing
- Develop job aids and quick reference guides as well as performance standards by which to monitor the appeal's team progress
- Ensure that all departmental policies, procedures, projects, and departmental activities meet requirements of applicable regulatory and accrediting agencies
- Maintain a thorough knowledge of regulations, accreditation standards and corporate standards that affect the appeals process
- Monitor the appeals volume and the number of appeals processed within the department to ensure both quality and adherence to contractual regulations
- Monitor department standards, identify opportunities for improvement, recommend and implement appropriate actions to ensure goals are met
- Prepare and conduct regular staff meetings
- Oversee orientation of new appeals staff
- Educate new and existing staff on compliance and appeals processes updates
- Interact effectively with medical management, operations, Provider Networks and Contracting, and executive management as well as members of the health plan and providers
- Analyze data for trends and process improvement
- Quality auditing and review data integrity, case summary packets, resolution letters and Maximus Packets before appeal closures.
A&G Pre-Service Appeals Supervisor
Molina Healthcare
2020.03 - 2020.08
- Managing a team of 7 reports (1 Supervisor and 1 Lead) and 5 Appeals Specialists
- Production oversight of member and provider pre-service appeals to ensure all contractual and regulatory agreements are met
- Monitoring productivity and quality and implement appropriate actions to ensure department goals are met
- QA of Appeals to ensure accuracy of case processing
- Develop job aids and quick reference guides as well as performance standards by which to monitor the appeal's team progress
- Ensure that all departmental policies, procedures, projects, and departmental activities meet requirements of applicable regulatory and accrediting agencies
- Maintain a thorough knowledge of regulations, accreditation standards and corporate standards that affect the appeals process
- Monitor the appeals volume and the number of appeals processed within the department to ensure both quality and adherence to contractual regulations
- Monitor department standards, identify opportunities for improvement, recommend and implement appropriate actions to ensure goals are met
- Prepare and conduct regular staff meetings
- Oversee orientation of new appeals staff
- Educate new and existing staff on compliance and appeals processes updates
- Interact effectively with medical management, operations, Provider Networks and Contracting, and executive management as well as members of the health plan and providers
- Analyze Data for trends and process improvement
- Quality auditing and review data integrity, case summary packets, resolution letters and Maximus Packets before appeal closures.
A&G Lead of Pre & Post Appeals
Molina Healthcare
2019.10 - 2020.03
- Reported directly to the Post Service Appeals Supervisor
- Co-Lead of both the Pre-Service and Post Service Appeals Team
- Served as an interim Supervisor for the Pre-Service Appeals Team
- QA of Appeals to ensure accuracy of case processing
- Point of contact for both Pre and Post Service Specialists (12 Specialists)
- Daily Inventory Reports and Summaries capturing all efforts to both the Pre-Service and Post Service Supervisors to include overall updates, successes, and challenges
- User acceptance testing (UAT) for systems performance and implementation
- Plan, execute and report the actual tests, interpret the test results, and help with potential obstacles to improve customer experience, increase member and provider satisfaction, and maintain uninterrupted business operations
- Provide interim quality auditing support by reviewing data integrity, case summary packets, resolution letters and Maximus Packets before appeal closures
- Prepare and conduct regular staff meetings
- Oversee orientation of new appeals staff
- Daily Appeals oversight and production reports.
Appeals & Grievances Analyst
Molina Healthcare Inc.
2016.10 - 2019.10
- Grievance & Appeals Specialist providing direct assistance to member and providers with health care access or benefit coordination issues, ensuring that grievances, complaints, and complex issues are investigated and resolved to the member and provider's satisfaction in a manner consistent with Molina Healthcare, CMS, and regulatory guidelines
- Managed a volume of 150 appeals at a time.
- Benefit coordination involves coordinating Medicare Benefits, Claim denials and Direct Member Reimbursement requests for dental, vision and medical benefits
- Responsible for submission, intervention and resolution of appeals, grievances, and/or complaints from Molina members and providers
- Research issues utilizing systems and clinical assessment skills, knowledge and approved “Decision Support Tools” in the decision-making process regarding health care services and care provided to members
- Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and collaborates with Medical Directors and other team members to determine response' assures timeliness and appropriateness of responses per state, federal and Molina Healthcare guidelines
- Prepares appeal summaries, correspondence, and documents information for tracking/trending data; assists in the preparation of narratives, graphs, and flowcharts.
- For presentations and audits.
Marketplace Escalations
Molina Healthcare Inc.
2016.01 - 2016.10
- Review of Top Tier Broker Issue and Resolution Requests.
- Direct contact with 10 Brokers to resolve issues, with a volume of 50 weekly.
- Interim Learning & Development Specialist
- New hire onboarding and training
- Enrollment and premium payment issues/ discrepancies; processing PCP changes, referral and authorization inquiries
- Claims that may have denied in error or interpreting the outcome of the claim to a member or provider
- Inappropriate billing (member's balanced billed by providers/ facilities), assisting providers in reprocessing claims and educating the provider with their appeal rights to stop balance billing
- Developing/ Structuring department Standard Operational Procedure documents (SOP's) and department workflows
- Training: Claims, Member Services, Billing Issues and Premium Payment.
Claims & Premium Payment Representative
Molina Healthcare Inc.
2015.01 - 2016.01
- Responsible for providing Claims and Appeals Status to Contracted and Non-Contracted Providers.
- Managed a high call volume; over a 100 calls a day.
- Familiarized with Medicaid, Medicare, MMP and Marketplace Claims
- Conducting Claims training for new Claim’s representatives
- Processing premium payments, assisting members with billing issues which may include unapplied or misapplied payments, invoice discrepancies and restrictions applied in error
- Provider and member eligibility and benefits inquiries (i.e., Co-Pays, Co-Ins., Deductible and OOPM accumulations).
Member and Provider Service Representative
LA Care Healthplan
2013.09 - 2015.01
- Managed provider and member calls effectively and efficiently in a complex, fast-paced, and challenging environment
- Answering incoming first level calls from member, potential members, providers, and advocates
- Handled and resolved member issues and or connecting members with internal units or external parties such as Plan Partners, PCP offices, pharmacies, etc
- Assisting members with essential information regarding access to care issues, coordination of care issues, Benefit Clarification, EOC, etc
- Assisting providers with claims & Appeals status inquiries
- Member and provider complaint and grievances
- Services as an interim Lead assisting a team of 35 call center representatives
- Interim training for new hires.
Credit & Activations Tech Support
AT&T
2011.12 - 2013.09
- Responsible for customer and sales agent calls
- Managed a call volume of 100 per day.
- Handled a range of tasks related to payment options, bill charges, overdue accounts and activations issues
- Sales Agent credit and activation Support
- Processing of Credit Applications
- Activation of new accounts and equipment.
Education
Bachelor of Arts - Psychology
California State University, Northridge
Northridge05.2010
Skills
- Appeals & Grievances
- Provider Dispute Resolution (PDR)
- Member and Provider Pre & Post Service Appeals
- State & Federal Regulations and Guidelines
- Medicare and Medi-Cal Benefits
- Claims Knowledge
- Quality Improvement Organization (QIO) Appeals
- Managed Care
- Leadership
- Strong verbal and communication skills
Accomplishments
- Resolved product issue through consumer testing.
- Manage a team of 36 staff members.
- Used Microsoft Excel to develop inventory tracking spreadsheets.
- Policy and Procedures updates to align with Medicare and Medi-Cal regulatory guidelines.
- Successfully transitioned PDRs from Claims Administration to A&G by working closely with Claims and Executive leadership.
- Successfully restructured the Provider and Intake teams for a more streamlined process.
Languages
English
Full Professional
Spanish
Full Professional
Timeline
Manager, Appeals & Grievances
CalOptima Health
2022.03 - Current
A&G Pre-Service Appeals Manager
Molina Healthcare
2021.11 - 2022.03
A&G Intake Manager
Molina Healthcare
2021.03 - 2021.11
A&G Post Service Appeals Supervisor
Molina Healthcare
2020.08 - 2021.03
A&G Pre-Service Appeals Supervisor
Molina Healthcare
2020.03 - 2020.08
A&G Lead of Pre & Post Appeals
Molina Healthcare
2019.10 - 2020.03
Appeals & Grievances Analyst
Molina Healthcare Inc.
2016.10 - 2019.10
Marketplace Escalations
Molina Healthcare Inc.
2016.01 - 2016.10
Claims & Premium Payment Representative
Molina Healthcare Inc.
2015.01 - 2016.01
Member and Provider Service Representative
LA Care Healthplan
2013.09 - 2015.01
Credit & Activations Tech Support
AT&T
2011.12 - 2013.09
Bachelor of Arts - Psychology
California State University, Northridge
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