LISA VALDES

Educate providers, staff and members on Health Plan benefits and services and applicable regulations. Accountable for accurate and timely identification, investigation and processing of all member/patient inquiries. Responsible for intake and resolution of End of Next Business Day (ENB) complaint and grievance cases within the Medical Center and medical offices. Responsible for partnering with internal and external staff and departments to provide creative, timely solutions for member concerns. Assists with training, audits and other activities as necessary.

Ensure that inquiry and ENB documentation and processing are completed in accordance with regulations, compliance standards, policies and procedures. Regulators include but are not limited to: Center for Medicare/Medicaid (CMS), California Department of Managed Healthcare (DMHC), Department of Health Services (DHS), Department of Labor, Department of Consumer Affairs, the National Committee for Quality Assurance (NCQA).

Create effective partnerships between Call Center and Member Services at the Medical Center to work collaboratively in responding to and resolving investigative complaints that are received at the call center Negotiate with facility, service area, and regional staff (as necessary) to reach satisfactory service solutions to issues that optimize our members experience with the services they receive.

• Operate in a high volume responding to incoming calls. Ascertain if calls are urgent or emergent by listening to the patient, following established guidelines.
• Collaborate with staff, nurses, physicians & outside vendors (i.e., Claim Adjusters). Compose messages to providers, staff, case coordinators, & nurses.
• Establish positive and trusting relationships with injured patients, & outside vendors administering efficient customer service.
• Determine the type of appointment, review medical charts and the scheduling mix of various physicians/providers, utilizing appropriate guidelines. Complete new intakes over the telephone and in person then accurately process claims for WC billing.
• Assure we have WC claim authorizations for visits and referrals. Save and convert files from PDF to Word.

• Reviewed and processesed billings received from outside medical providers.
• Provider Data and LOA management. Process FALCK and Member Reimbursement Claims.
• Processed Medicare claims utilizing CONNECTU and DPL.
• Kept Updates for Government Regulatory Policies and Compliancy of CMS, DMHC, & DHS.

• Performed Hospital Quality Audits for accurate billing.
• Identified healthcare resources and government programs for patients unable to meet financial obligations consistently meeting 99% of targeted goals.
• Admissions for Inpatient, Outpatient & Surgery.
• Obtained pre-authorizations for Inpatient care. Assisting & collaborating with case managers.
• Collected large sums of copayments in cash and using PCI Payment Card Industry
• Assisted members with billing inquiries.

• Processed billing calls and answered questions from patients and third-party carriers.
• Compiled and tracked outstanding balances owed to medical facilities.
• Corrected, completed and processed claims for multiple payer codes.
• Processed online and paper appeal submissions.
• Assisted in reconciling deposit and patient collections.
• Logged charges and payments within office systems.
• Generated financial statements and reports detailing accounts receivable status.
• Communicated with insurance providers to resolve denied claims and resubmitted.
• Reviewed patient records, identified medical codes and created invoices for billing purposes.
• Reviewed patient diagnosis codes to verify accuracy and completeness.
• Liaised between patients, insurance companies and billing office.
• Set up and maintained new electronic billing system.