Lillian Gonzalez

Business professional with supervisory experience in the Health Insurance sector. Flexible and Quick learner who adapts easily to new situations and enjoys a challenge. Self-motivated professional with a commitment to providing quality service. Strong organizational and communication skills.

• Trained OFF SHORE Data loaders.
• SME to THE OFF SHORE Data loaders.
• Worked escalated projects within quick turnaround times
• Implementation of an electronic filing system in a Medical office.
• Subject Matter Expert for the Northeast line of business during the creation of the policies and procedures of the call center.
• Increased by 20% the performance levels of the call center staff through a review of the monitored calls.
• Increased by 80% audit analyst performance levels by collaborating to create an error free tracking system.
• Collaborated on the creation of the Arizona line of business policy and procedures.
• Researched, resolved and documented all enrollment issues.
• Translated Spanish calls for the Customer Service Department.
• Verified claim processing accuracy to ensure cost savings for the company.
• Traveled and trained California employees on business processes.

• United HealthCare, Business Process Analyst, Provider Quality Management, 2023-01-01, Present, Lead the PDA Submission Audit Program & Secret Shopper Dental Program, Collaboration with Optum Dental, Lead for the Federated MI audit, Trained MI Audit Program, Facilitate Daily Huddles, Resource for team, Analyze Raw Data, Identify Trends, Root cause & suggest a course of action, Responsible for sharing the results of the Data monthly via Cross Functional Meetings, Collaboration with leads of CAQH on Accepting New Patients defects as well as Specialty defects, Recommendations to have Job Aids/SOPs updated, Review and appeal audits for Secret Shopper calls, Meet with global Business Partners to discuss appeals, Project Management support, Assist the RIDeS (Roadmap Idea Development Support) team with backlog, Diversity, Equity & Inclusion Ally for PDO, Participate on the PDA (Secret Shopper) Weekly Progress & Working Session, Roster Management, CAQH Provider Data Portal for Groups (PDPFG) Implementation/Adoption Workgroup Meeting, Created Action items Log tracker and follow up with responsible parties, Member of the Employee Engagement committee, Create AI notes for meetings, Trained Business Partners to run AI meeting notes, BSAR project involvement (C&S Line of Business)
• United HealthCare, Provider Data Analyst, Audit Liaison Team, 2018-01-01, 2023-12-31, Daily Huddles, Act as Team SME for team, Perform & Validate End to End audits on all platforms for E2 Physician, E2E Onboarding, E2E Roster, and E2E Focus, NTT, Wipro, and FYIs, Designated ALT on Michigan audits., Open communication with BP and QuEST, Submit appeals on behalf of the BP via ERSP, Submit Titan2 RnR Intakes for BP, Submit Titan2 DA intakes, Review BAPA requests, Worked the COVID audit Project, Help support 2nd level appeals, Assist with Daily Leadership Calls, Worked on the BSARS Fallout project, Work with TQM on DC43 project, Assisted in building the Roster Training Guide, Trained Team on CLM, COMSOS and CSP, Worked on the Directory Indicator Project, Pitched in on the NDB Back End Testing Project, Active participant in the DEI Awareness and Growth Workstream, Performed audits for Jeremy parks on a NC Audit, Identify Trends
• United HealthCare, Provider Data Analyst, QuEST, 2017-01-01, 2018-12-31, Daily Huddle, Research & Audit Contract Line of Business, Research & Audit Fee Schedule Line of Business, Research & Audit Term Contract, Research & Audit Contracts Demographics, Perform End to End audits on all platforms impacted, Document audit findings in the QI Access Database, Assign errors based on Business SOPs/SOT and document on ERSP share point site, Direct the Business Partners to the SOPs to assist in understanding the error assessed, Provide documentation to support errors assessed, Establish relationships with Business Partners, Identify and report a break in business SOPs, Identify Trends, Obtain credential status, Resource to my peers as well as Business Partners, Submit and validate audits timely, Vital Signs Work Group, Selected to work special projects such as: Time Studies, QI studies, Mock Audits, Collaborate to develop a new & enhanced QVC Program for Quest, Perform Audits for the Focused Audit Team, Communication Liaison for my team, Appeal RB audits, Identify & Submit Out of Scope Audits, Assist trainees transition to new responsibilities, Audit the trainees
• United HealthCare, Audit Liaison, Tricare, 2014-01-01, 2017-12-31, Perform 2nd level audits to validate or appeal audit findings, Submit appeals with proper supporting documentation, Ensure Business Operations Process is followed, Identify and analyze process gaps, Contribute with SOP updates, Prioritize and Organize work to meet deadlines, Identify trends & provide input and/or suggestions, Provide Business with TIP of the week via PowerPoint, Lead Quality Circle Calls, Lead Rebuttal calls, Utilize database system to document audit findings, Maintain current knowledge of procedures, Work closely with BPQM and Business Operations, Validate corrections
• United HealthCare, Provider Data Analyst, Delegated Roster Management, 2013-01-01, 2014-12-31, Work closely with Network Management and Delegate Contact, Update Delegate information into the NDB platform system, Train PhyCon system, Train New Hires, Assign work, Resource contact for the team, Daily Inventory of work items assigned, Audit, Provide feedback regarding audit findings, Contact with Management team, Weekly DRM Meetings, Work escalated items to ensure a quick turnaround, Load, Research and Validate through the PhyCon system, Access and Update Information to the Titan Database
• United HealthCare, Provider Data Analyst, Tricare, 2013-01-01, 2013-12-31, Contract loads for providers and physician groups, Perform data reconciliation, Load new physician demographics, Installation of contracts and fee schedules, Provide maintenance on provider loads and physician demographics, Ensure affiliations are executed, Maintenance on contracts and fee schedules, Train staff, Subject Matter Expert
• Connecticut Fertility Associates, Office Manager, 2012-01-01, 2012-12-31, Organize office operations and procedures., Recruit, orient and train staff., Supervise and evaluate staff performance., Ensure coaching, counseling and discipline were delivered., Assign and monitor clerical and secretarial functions., Implementation of the organization’s flow chart, electronic filing system, job descriptions, training module and work schedule., Assisted in answering phones and scheduling of appointments., Provide management oversight for registration and scheduling of patients, Assisted with translation., Maintained collections for the practice including co-pays and not limited to overdue balances., Daily morning meetings with reception area.
• Connecticut Fertility Associates, Benefit and Financial Coordinator, 2011-01-01, 2012-12-31, Provide excellent customer service., Heavy phone contact with Insurance companies for benefits, eligibility and authorizations., Direct interaction with patients for financial consultation and benefit review, Maintained inventory of Prescriptions., Financial counseling with patients to ensure payment is collected prior to procedure., Weekly meetings with clinical staff regarding Invitro- Fertilization patients., Weekly meetings with billing staff., Implemented Financial Consultation forms., Direct contact with drug vendors., Email interaction with prospective patient.
• Health Net of the Northeast, Quality Improvement Team Lead/Senior Audit Analyst, 2001-01-01, 2011-12-31, Supervise quality staff of five Audit Analysts., Subject Matter Expert for the Northeast line of business during the creation of the Policies and Procedures of the Call Center., Identify training needs arrange/coordinate attendance at required trainings., Ensure departmental deliverables by maintaining balanced workflow among staff., Increased by 20% the performance levels of the call center staff through review of monitored calls., Identify opportunities and make recommendations to improve quality and increase production efficiencies by ensuring Audit Analyst are cross trained., Chair meetings call center wide., Train the Call Center Staff on the Quality Assurance Program., Resolved quality assurance disputes within established guidelines and timeframes., Maintain adherence to Sarbanes Oxley requirements., Collaborate to implement the Quality Performance Evaluation Records., Convey feedback to call center agents by making recommendations for quality improvements, skill development and training to enhance customer service and productivity., Liaison between the Call Center Supervisors, Quality Improvement and Audit Analysts., Collaborate with the Business Analysts to evaluate and report trends., Collaborated on the creation of the audit tracking tool and the various revisions., Increased by 80% audit analyst performance levels by collaborating to create an error tracking system., Collaborated on the creation of the Arizona line of business policy and procedures., Project Manager for the creation of a new call center unit., Participated in the interview process for new audit analysts., Co-Chair Morale committee for the 400+ call center staff.
• Health Net of the Northeast, Senior Enrollment Specialist: Special Accounts, 1998-01-01, 2001-12-31, Reviewed and processed enrollment documents submitted from clients., Reconciled member eligibility issues through comprehensive research resulting in cost savings., Researched, resolved and documented all enrollment issues., Compiled data and prepared reports reflecting daily statistics within the department for management., Demonstrated project support for call departments., Telephone support to the Special Accounts Management team regarding eligibility issues to determine enrollment/disenrollment.