La Nacia Vargas
Katy,TX
Summary
Experienced healthcare and claims professional with expertise in grievances, appeals, and claims processing across diverse industries. Proven success in leading teams, managing high-volume caseloads, and resolving complex disputes in compliance with regulatory standards. Strong background in healthcare supervision and service excellence.
Overview
9
9
years of professional experience
Work History
Grievances & Appeals Specialist
Molina Healthcare
06.2023 - 10.2024
- Managed grievances and appeals, ensuring compliance with regulatory timelines and accuracy in case handling
- Investigated and resolved complaints and appeals for members and providers, documenting outcomes thoroughly
- Collaborated with healthcare providers and regulatory agencies to ensure accurate claim resolutions.
Claims Processing Specialist
Aerotek (River City Medical)
05.2022 - 06.2023
- Processed medical claims with a focus on accuracy and efficiency, reviewing documentation for compliance with health plan requirements
- Handled appeals and grievances, conducting thorough investigations to support claim decisions
- Provided customer service support to healthcare providers and plan members to resolve claims-related issues.
Claims & Appeals Coordinator (Non-Medical)
Randstad
01.2022 - 06.2023
- Processed non-medical claims and handled appeals within strict deadlines, ensuring compliance with relevant regulations
- Worked with cross-functional teams to resolve claims discrepancies and communicate resolutions to stakeholders
- Managed documentation and case notes in internal systems for accurate reporting.
Supervisor, Appeals & Grievances
Health Sherpa (Seasonal Supervisor)
08.2021 - 01.2022
- Supervised a team of claims processors and appeals specialists, ensuring high-quality service during peak open enrollment season
- Managed escalated grievances and appeals, ensuring that member concerns were addressed and resolved promptly
- Provided training and support to new team members, focusing on policy compliance and quality control.
Supervisor, Claims Processing
Triwest Health Care Alliance
10.2015 - 08.2020
- Supervised claims processing operations, overseeing a team responsible for handling high volumes of medical claims
- Led investigations into complex claim appeals and grievances, presenting findings to management for resolution
- Monitored claim trends to identify potential issues and worked with cross-functional teams to develop solutions.
Education
Bachelor of Science - Helath Care Managment
University of Phoenix
Tempe, AZSkills
- Medical Claims Processing
- Grievances & Appeals
- Regulatory Compliance (HIPAA, CMS)
- Healthcare & Non-Medical Claims
- Data Analysis & Reporting
- Team Leadership & Supervision
- Conflict Resolution
- Cross-functional Collaboration
Timeline
Grievances & Appeals Specialist
Molina Healthcare
06.2023 - 10.2024
Claims Processing Specialist
Aerotek (River City Medical)
05.2022 - 06.2023
Claims & Appeals Coordinator (Non-Medical)
Randstad
01.2022 - 06.2023
Supervisor, Appeals & Grievances
Health Sherpa (Seasonal Supervisor)
08.2021 - 01.2022
Supervisor, Claims Processing
Triwest Health Care Alliance
10.2015 - 08.2020
Bachelor of Science - Helath Care Managment
University of Phoenix
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