Lissette Criollo Cortes
New York,NY
Summary
Dedicated professional with history of meeting company goals utilizing consistent and organized practices. Skilled in working under pressure and adapting to new situations and challenges to best enhance the organizational brand.
Overview
14
14
years of professional experience
Work History
SENIOR ASSOCIATE, GRIEVANCES & COMPLAINT MGMT
Cityblock Health
04.2023 - 04.2024
- Record and evaluate complaint and grievances submissions, ensuring timely processing of complaints
- Coordinate with internal departments (Customer Service, Compliance, Care Teams, Quality Assurance) to incorporate vital input reports
- Record and provide regulatory reportability decisions on complaints as well as assist in preparation for audits and inspections
- Perform root cause investigations and assist in CAP (Corrective Action Plan) activities
- Collect complaint cases and process metrics to capture and generate trend reports
- Responsible for quality assurance of communications from inbound and outbound teams
- Ensure all teams are compliant with all HIPAA regulations and state and federal requirements
- Interpret rules and regulations to provide guidance on how we can proceed to advance our mission within those guideline
- Communicate across markets, making teams aware of compliance outliers, creating solutions for gaps in processes related to compliance
GRIEVANCE & APPEALS SPECIALIST
EmblemHealth
10.2021 - 04.2023
- Respond to written/verbal grievances, complaints, appeals and disputes submitted by members and providers.
- Review, analyze, research, resolve and respond to all types, in accordance with guidelines established by Centers for Medicare and Medicaid (“CMS”), CT/NY State and other regulatory agencies, where applicable, as well as internal policies.
- Process appeals to facilitate accurate administration of benefits and clinical policy; ensure compliance of appeals process with all regulatory requirements and NCQA standards.
- Work as effective interface between internal and external customers.
- Maintain good member and provider relations.
- Review and evaluate appeal and grievance requests to identify and classify member and provider appeals; process member and provider appeals and complaints as appropriate to meet CMS, State and Accreditation requirements.
- Determine eligibility, benefits, and prior activity related to claims, payment or service in question.
- Review research performed by operational areas to ensure appropriate resolution to ap- peal/grievance has been achieved: review contracts, member materials, medical payment policies, and provider education documents in researching and deciding outcome of appeals.
- Accountable for appropriate review and determination in compliance with state and federal regulations and NCQA.
- After review, determine if denied service or claim should be reversed; or consult with Medical Director to complete final determination.
- Delegate physician review as appropriate to Medical Director or Independent Review Organization(s).
- Conduct thorough investigations of all member and provider correspondence by analyzing all issues involved and obtaining responses and information from internal and external entities.
- Perform comprehensive research related to facts and circumstances of member complaint, to include appropriate classification as grievance, appeal, or both, in accordance with regulatory requirements.
- Research appeal files for completeness and accuracy and investigate deficiencies.
- Consult with internal areas as required (such as Legal Department) to clarify legal ramifications around complex appeals.
- Adjudicate claims in accordance with most current policy benefits, limitations or exclusion and claims policies and procedures.
- Provide written acknowledgment of member and provider correspondence; prepare written responses to all member and provider correspondence that appropriately address each complainant's issues and are structurally accurate.
- Follow-up with responsible departments and delegated entities to ensure compliance.
- Responsible for making verbal contact with member or authorized representative during research process to further clarify, as needed, member's complaint.
- Ensure documentation requirements are met: create and document service requests to track and resolve issues; document final resolutions along with all required data to facilitate accurate reporting, tracking and trending.
- Provide all follow up documentation of outcome to practitioners, providers, and members.
- Responsible for timely, complete, accurate documentation of appeal and/or grievance both electronically and in hard copy; and for timely and accurate written documentation to member and/or provider advising of resolution of appeal and/or grievance.
- Prepare cases for medical and administrative review detailing findings of their investigation for consideration in plan's determination; case summaries for appeal resolution notification; and send completed cases for scanning.
- Responsible for ensuring appeals case files are accurately prepared and submitted to IRE within 24 hours of decision to uphold initial denial for expedited appeals, and not later than 30 calendar days after receipt of standard pre-service appeal and 60 calendar days after receipt of claim appeal.
- Ensure daily production log and team database is maintained; manage database for physician review appeals in support of business requirements, regulatory obligations and NCQA; monitor daily and weekly pending reports and personal worklists, ensuring internal and regulatory timeframes are met.
- Enter and maintain critical data and records in support of business requirements, regulatory timeframes, and NCQA standards, into appropriate systems.
- Track and trend outcomes; and analyze data to provide reporting as required for UM, QA, etc., and to identify provider education opportunities.
- Responsible for monitoring effectuation of all resolution/outcomes resulting from appeals, Administrative Law Judge, and Medicare Appeals Council processes.
- Identify areas of potential improvement and provide feedback and recommendations to management on issue resolution, quality improvement, network contracting, policies and procedures, administrative costs, cost saving opportunities, best practices, and performance issues.
- Serve as liaison with EmblemHealth departments, delegated entities, medical groups and net- work physicians to ensure timely resolution of cases; collaborate and partner with internal departments for resolution and education; work with physicians, hospitals and internal staff to gather information needed to resolve complex claim issues.
GRIEVANCE & APPEALS COORDINATOR
Centers Plan for Healthy Living
09.2019 - 08.2020
- Logged and tracked verbal or written member grievances and appeals.
- Conducted relevant research into complaints and collaborated, coordinated and communicated with various departments (i.e. Member Services, Care Management, Claims),as well as external entities (i.e. Providers and Vendors) to collect additional information as necessary.
- Maintained current knowledge of plan products, policies and procedures with ability to relate acquired knowledge in clear, concise and understandable manner to members, providers, and internal staff.
- Ensured grievances and appeals were handled and resolved in compliance with timeliness requirements and at highest standards for accuracy.
- Prepared, generated, and mailed letters, forms, and other G&A-related notices.
- Maintained confidentiality of all protected health information in accordance with state, federal, and corporate guidelines.
PROGRAM ASSOCIATE
Fidelis Care
07.2019 - 09.2019
- Created spreadsheets with appropriate data, as requested and assigned; provided others with organized statistical reports or graphs.
- Problem-solved nonclinical issues; ordered and maintained such services as meals on wheels, DVRs, purchasing of medical supplies and non-medical essentials.
- Provided phone coverage and clerical support to team.
- Placed follow-up telephone calls.
- Assisted staff within teams to facilitate workflow and ensure efficient service to customers.
- Coordinated/implemented mailings.
- Assisted in preparing monthly audits.
- Provided support to members of department and supported various department functions.
- Handled data entry and maintained database.
- Handled follow-up telephone calls.
MEMBER SERVICES ASSOCIATE
Fidelis Care
11.2015 - 07.2019
- Responded to telephone or written correspondence inquiries from members and/or providers within established time frames utilizing current reference materials and available resources.
- Provided assistance to members and/or providers regarding website registration and navigation.
- Documented all activities for quality and metrics reporting through Customer Relationship Management (CRM) application.
- Processed written customer correspondence and provided appropriate level of timely follow-up.
- Coordinated member transportation and made referrals to other departments as appropriate.
- Maintained performance and quality standards based on established call center metrics including turn-around times.
HOSPITAL CARE INVESTIGATOR
Elmhurst Hospital
12.2014 - 06.2015
- Conducted in-depth financial interviews with patients to obtain accurate demographics (e.g. Birthplace, current address & phone number, mother's maiden name, etc.) insurance eligibility or assisted the uninsured with HHC Options that included processing Medicaid applications (if eligible) and advised patients of various payment options.
- Utilized all available resources, e.g. Insurance company websites, ePaces, Epic, ONBASE, AIM, and NYS Marketplace to process patient information/eligibility in order to obtain approval for their hospital inpatient stay.
- Logged into Epic (WQ-15661) on a daily basis and WQ- 11920, 11928 & 9323 on weekends.
- Maintained current access to all required software applications to perform assigned duties, by periodically resetting/changing passwords.
- Updated demographics, insurance information, input authorizations into EPIC; documented activities relative to obtaining authorization/approvals in Epic Hospital Account notes.
- Scanned pertinent information into ONBASE under medical record number or HAR; for example -patient identification, insurance card, authorization letters, appeals, correspondence, etc.
- Interviewed Emergency Room patients to obtain insurance information and complete Medicaid Applications.
- Obtained signatures on Observation Forms.
- Completed assignments in timely manner; adhered to Financial Clearance Standard Work.
- Consulted with Senior Hospital Care Investigator, on problematic issues and/or cases to facilitate processing.
- Functioned as integral Team member, communicating regularly and working collaboratively, contributing to the operational flow within unit while enhancing patient experience.
- Communicated satisfactorily, both verbally & written.
- Actively participated in Unit/Departmental huddles on daily/weekly basis.
- Possessed basic mathematical skills, e.g. Added, subtracted, multiplied and divided various units of measure using whole numbers, common fractions and decimals to compile statistical data.
- Safeguarded PHI (Protected Health Information) by keeping it insight or secured at individual workstation.
- Practiced patient confidentiality by not discussing specific patient related issues in open areas.
- Demonstrated commitment and accountability to be culturally sensitive to internal & external, irrespective of race, color, national origin, religion, gender.
- Comprehended Breakthrough concept; achieved Green Certification; incorporated applicable techniques into work performance.
- Adhered to Health+ Hospital's six Guiding Principles.
- Abided by Corporate, Hospital & Departmental policy regarding the use of a cell phone for emergency purposes only while at workstation.
- Attended in-service, Departmental, Hospital & Healthcare related trainings.
- Maintained compliance with OHS annual assessment, Multistar, Fire Safety, HIPAA as well as Fraud& Abuse training.
- Followed Departmental Policies & Procedures, including the call-in and dress code policies.
OFFICE MANAGER
New York & Oral Facial Surgery
03.2012 - 12.2014
- Hired, terminated, and trained staff
- Supervised secretaries, receptionists, and medical billers and coders
- Oversaw billing, coding, and collections
- Scheduled appointments
- Maintained medical records
- Made deposits
- Reconciled account information
- Paid office bills
- Arranged cleaning staff
- Arranged for emergency maintenance visits for building
- Ordered medical and office supplies
- Submitted claims to insurance
- Processed company's response to claims
- Submitted billing statements to patients
- Delegated responsibilities
- Assessed employee performance
- Performed data entry and processing
- Developed and implemented office policies and procedures
- Formulated objectives and processes
- Generated inventory records
- Provided educational material for patients.
SCHEDULING COORDINATOR
Steinway Family Dental Center LLP
11.2009 - 03.2012
- Developed and maintained doctor/hygienist schedule to meet practice goals.
- Responsible for answering incoming calls to include, new patient calls, emergencies, scheduling patient appointments, requesting records, and follow up.
- Managed unscheduled list, asap list, treatment pending list, to ensure patient follow through to meet scheduling goals.
- Greeted and checked patients in and out for and after treatment.
- Educated and consulted patients, discussed treatment needs and presented treatment plans.
- Increased and stimulated new patient growth by supporting marketing and promotional programs, to include recall cards, continuing care calls, referral letters and gifts, and working with referrals.
- Documented patient dental treatments and financial transactions, to include signing of financial arrangements, prepayments for large cases, financing, and charges collection.
- Made pre-treatment financial arrangements with patients.
- Responsible for billing dental insurance, posting payments, and claim estimations.
- Balanced income and charges daily and prepared deposits.
- Responsible for Accounts Receivable to include, sending of billing statements, aging reports, and collections.
- Created month end reports and forecasted monthly goals for office and providers.
- Followed office procedures for patient referrals.
- Responded to doctor, patient and employee concerns and inquiries and sought assistance when necessary.
Education
Associate of Science - Nursing
LaGuardia Community College
Queens, NY06.2026
High School Diploma -
The Mary Louis Academy
Jamaica, NY06.1993
Skills
- Preparation of Appeals
- Written Communication
- Documentation Research
- HIPAA Compliance
- Federal Regulations
- Retaining Information
- Analyzing Information
- Managing Case Files
Languages
English
Spanish
Timeline
SENIOR ASSOCIATE, GRIEVANCES & COMPLAINT MGMT
Cityblock Health
04.2023 - 04.2024
GRIEVANCE & APPEALS SPECIALIST
EmblemHealth
10.2021 - 04.2023
GRIEVANCE & APPEALS COORDINATOR
Centers Plan for Healthy Living
09.2019 - 08.2020
PROGRAM ASSOCIATE
Fidelis Care
07.2019 - 09.2019
MEMBER SERVICES ASSOCIATE
Fidelis Care
11.2015 - 07.2019
HOSPITAL CARE INVESTIGATOR
Elmhurst Hospital
12.2014 - 06.2015
OFFICE MANAGER
New York & Oral Facial Surgery
03.2012 - 12.2014
SCHEDULING COORDINATOR
Steinway Family Dental Center LLP
11.2009 - 03.2012
Associate of Science - Nursing
LaGuardia Community College
High School Diploma -
The Mary Louis Academy