MESHVA JARIWALA

• Lead and participated in continuous quality improvement initiatives and served as a resource to others regarding quality concerns.
• Conducted large scale audits for DMHC, DHCS’s NCQA, CalViva, IRO cases with minimum supervision from leadership. E
• Conducted internal audits and identified, developed, and executed appropriate training programs applicable to the needs of the business to avoid quality risks by identifying trends and patterns of the audits.
• Introduced Power Bi/SQL to the team to create feedback reports as well as Track and Trend report.
• Collaborated with cross-functional departments to identify training needs, perform root-cause analysis, system errors, processing errors, etc. and developed work plans and processes.
• Identified, developed and executed appropriate training programs applicable to the needs of the business and based on identified trends and patterns.
• Handled various projects with minimum supervision to meet timelines.
• Collaborated with technical, non-technical business partners, vendors, etc. to support multiple quality functions and levels of the organization and effectively.

• Researched, gathered, and examined information for quality of service grievances and member appeals
• Mentored new coordinators through daily training sessions and one-on-one advising
• Wrote responses for members' grievances and appeals upon case findings
• Followed up and maintained grievances and appeals cases on a daily basis
• Handled provider calls, member calls, and internal communication
• Performed research on various issues
• Determined when a grievance or an appeal required escalation
• Identified gaps and performed outreach to internal departments, PPGs, PNAs, facilities, provider offices, and vendors to obtain information, medical records, and relevant documentation needed
• Completed grievance and appeal resolution letters using appropriate templates for respective types of case using any relevant attachments for members to review and arranged for translation letters if needed
• Performed any other duties as assigned
• Line of business Efficient in: HMO, PPO, Medicare

• Handled Members, Provider, Sales Agent or Brokers calls concerning eligibility, benefits, provider information, clinical inquiries, pharmacy needs, billing inquiries, medical claim inquiries, transportation inquiries
• Coordinated membership changes such as member’s Primary Care Physician
• Conducted resolution of pharmacy calls concerning benefits, co-pays, formulary, coverage, vacation overrides, and utilization management requirements
• Issued necessary documents as per Members needs such as: EOC, SOB, I.D Cards, Provider and Pharmacy Directories
• Fulfilled pharmacy needs such as help refilling member’s Rx by going over a denied claim with Pharmacy, Pharmacist or Pharmacy Tech by assessing the issue and help fix it for a successful claim reprocessing
• Performed inventory reduction (i.e
• Member inquiries, initiated claims adjustments, responded to emails)
• Assisted Members reinstate, disenroll, sign up into the plans, make payments on the account, review Billing Summary review their medical claims
• Line of Business Efficient in: Medicare Supplement: All Open and Closed Plans, Medicare Advantage MAPD: Blue Shield 65 Plus, Blue Shield Inspire, Blue Shield Vital, Blue Shield AdvantageOptimum and Blue Shield TotalDual Plan (HMO DSNP) and Blue Shield Coordinated Choice Plan, Medicare prescription drug plans PDP: Blue Shield Rx Plan and Blue Shield Rx Enhanced

• Credentialed and contracted providers with insurance company
• Verified all insurance information, referrals and authorizations for all scheduled procedures by maintaining a daily VOB
• Informed management of any pending issues which might delay ability to perform scheduled procedure
• Worked an attorney AR till the case is settled
• Assisted with ins AR by exporting reports for each Doctor, and determining claims that require follow up
• Worked on patient AR
• Applied payments for each Doctor ensuring that the insurance paid the correct contracted rate
• AR specialist and collections specialist
• Entered charges with accurate CPT codes and submitted claims for Doctors
• Specialties/ Facilities worked on: Cardiology, Internal Medicine, Pediatrician, Burn Unit and Personal Injury

• Orchestrated day to day administrative functions of the clinic, including but not limited to auditing the authorizations for procedures, insurance verification, office visits, medications prior authorizations, clerical functions, patient billing and accounting functions, over saw the reception, patient scheduling for procedures
• Conducted cash management, receivables and payables, monitored accurate patient transactions
• Inventoried the entire clinic supplies stock
• Managed, administered and promoted clinics website with multiple platforms
• Developed, implemented, and maintained policy and procedures within the clinic
• Completed timely and accurate documentation of all patient visits
• Complied with company policies, ethics and values
• Specialty worked on: Gastroenterology and Aesthetics

• Coordinated, evaluated and assisted the daily operations of the clinic with the clinical manager
• Supported clinics operation effectiveness and effectively communicated with the medical and management staff to run day to day functions
• Promoted and facilitated patient education and staff development
• Managed front office duty by greeting patients, verifying initial paperwork, and creating follow up appointments
• Scheduled procedures with thorough and straightforward explanation of the process to patients and family
• Verified insurance eligibility, maintained patient records compliant with HIPAA regulations, submitted prior-authorization requests
• Communicated regularly and clearly to members of an interdisciplinary team including physicians, administrative, executive, technical and support personnel at surgery centers
• Ensured top notch patient satisfaction and retention
• Conducted personal assistant duties for head Gastroenterologist

• Made pre-rounds and rounds on floor with the Neurocritical Care Director Dr
• Paul Vespa and team
• Discussed and documented additional patient cases with NP and other medical staff after rounds.

• Audited medical team by paper-based observation questionnaires as per the guidelines suggested by JC.

• Observed and documented the medical team during patient evaluation and various procedures related to vein treatment.

• Built and managed a high-performing style specialist team to run a million-dollar store
• Lead sales floor management and operations to maximize volume potential and achieve sales and KPI goals
• Manage training, developing, and coaching of associates on product trends and selling behavior strategies
• Analyzed various business reports to understand trends and opportunities.

• Worked with fraternity President to produce a medically-related lecture for all the CSUN community.

• Collaborated with the VP of Programming to create professional speaker events and medical school tours
• Organized all fraternity events geared toward professional development.

• Planned and supervised a team to raise funds for patients at CHLA totaling $15,000.

• Organized raising $10,000 for Children's Miracle Network Hospitals and Children’s Hospital Los Angeles.

• Organized service projects and events like Blood Drives and Bone Marrow Drives
• Liaison with philanthropy Children’s Miracle Network and other philanthropies.

• Processed patient discharges
• Helped nurses refill medication stock and update charts.

• Liaison between surgeons and families for patient status
• Front Desk Reception including telephone duty, directory services, and visitor greeting.

• Assisted nurses with various tasks for patient care
• Inventory control including the stocking and systematic arrangement of various medications.

• Organized activities in the volunteer department to raise money for patient care
• Prepared holiday gifts for patients and volunteers.