Melissa S. Cook
Sacramento,CA
Summary
Vibrant Senior Operations Specialist with an 8 year track record combining analysis, critical thinking, and gravitas to meet stakeholder objectives. Skilled in research and problem solving. Never afraid to ask a question, and the last to say, "that not my job."
Overview
8
8
years of professional experience
1
1
Certification
Work History
Senior Operations Specialist
Blue Shield of California
Rancho Cordova, CA
03.2021 - Current
- Researches and responds to regulatory provider complaints made to the Department of Managed Health Care and the California Department of Insurance .
- Utilizes an extensive knowledge of business acumen across multiple business units to respond to requests related to the fair payment practices of claims and health plan payor relations.
- Adeptly identifies monthly Provider Dispute trends for the Commercial Business Unit and presents solution propositions to improve efficiency and lower costs.
- Possesses a strong understanding of the Facets claims processing strengths, opportunities, and limitations.
- Interprets and synthesizes Professional and Facility Contracts.
- Conducts quarterly mock regulatory audits and develops process improvement solutions based on findings to improve regulatory compliance metrics.
- Collaborates with internal staff of all business levels to reduce silos and complete project objectives.
Business Analyst
Blue Shield of California
Rancho Cordova, CA
09.2019 - 03.2021
- Provided consultant level insight and implemented a process improvement to improve quality for the Ambulatory Surgery Center Program.
- Effectively supported program operations for Genetics, Ambulatory Surgery Center Steerage, Emergency Department Redirection, and Oncology programs with data requests, claims review, and resolution of operational barriers.
- Supported strategy development to increase member access and utilization of telemedicine and other self-help care options.
- Developed, prepared, and analyzed data reports for management review, and presented to various levels of management.
- Conducted root cause analysis research to optimize cost of healthcare savings.
- Identified leads for potential outreach and education for Regional Medical Directors.
Provider Relations Coordinator, Experienced
Blue Shield of California
Rancho Cordova, CA
11.2016 - 09.2019
- Established and maintained favorable relationships within the provider community; advocated to resolve and mitigate Provider issues.
- Trained new hires and facilitated onboarding training.
- Daily projects encompassed claims, medical policy, contract, data analysis, and utilization management acumen.
- Identified solutions for operational improvements and worked cross functionally to implement strategic business solutions.
- Provided data reporting and analysis to resolve issues ranging from claims, provider data, and access to care.
- Coordinated escalated claim disputes and often collaborated across multiple departments within Blue Shield to research and resolve escalations and errors.
Clinical Appeals and Grievance Coordinator
Blue Shield of California
El Dorado Hills, CA
08.2015 - 11.2016
- Audited and prepared member complaint cases and letters related to the denial of services based on medical necessity or investigational and experimental determinations.
- Quickly identified barriers, evaluated solutions, and concisely summarized plans to solve complex issues.
- Assumed responsibility and judgment within the scope and authority of the position.
- Collaborated with various business units throughout the organization to accurately resolve complaints with last touch resolution.
- Developed succinct external communications letters and formal responses related to the member's appeal.
- Provided chair side support for new hires.
Education
Associate of Arts - Arts And Humanities /Interdisciplinary Studies
B.A. - Business Administration
2023
- Professional Development consisting of Linkedin Learning Courses: Project Management: Healthcare Projects, Diversion, Inclusion, and Belonging, and Learning Program Management
- Active engagement with Professional Development Mentor
Skills
- Program Optimization
- Business Leadership
- Corrective Actions
- Process Improvement Strategies
- Procedure Writing
- Customer Feedback
- Motivational Leadership
- Root Cause Analysis
- The Silo Breaker
- Pivot Tables
- Business Presentations
- Problem Resolution
Certification
Lean Sigma Training
Vendor Management
Project Management
Work Availability
monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Timeline
Senior Operations Specialist - Blue Shield of California
03.2021 - Current
Business Analyst - Blue Shield of California
09.2019 - 03.2021
Provider Relations Coordinator, Experienced - Blue Shield of California
11.2016 - 09.2019
Clinical Appeals and Grievance Coordinator - Blue Shield of California
08.2015 - 11.2016
San Joaquin Delta College - Associate of Arts, Arts And Humanities /Interdisciplinary Studies
University of Arizona Global Campus - B.A., Business Administration
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