Miriam Ramirez
LA Care Health Plan
Los Angeles,CA
2
Languages
12
years of professional experience
- Please consider application for position. Current employment within organization provides strong understanding of department operations and supports fit for role. Confidence remains high in ability to contribute valuable skills.
- Experience in department has built useful insight into field. Training in provider services has strengthened knowledge and support for providers. Interest remains strong in taking on new challenges in different department.
- Stress management, deadline follow-through, and service support for members and providers reflect strong readiness for role. Communication, organization, and teamwork skills support effective collaboration. Opportunity for growth within organization would be greatly appreciated while continuing commitment to company mission.
Work History
Provider Network Management Coordinator II
2 Years 2 Months- The responsibilities included supporting the development of contract clauses and addenda; reviewing and negotiating new contracts and amendments, along with other documents related to contracts, in line with LAC contracting guidelines; engaging in discussions about leadership strategies; executing contracts and amendments across LAC; and organizing provider in-service orientation sessions. This role is responsible for monitoring the expiration and renewal of managed care contracts. It also involves investigating and resolving provider inquiries that have been escalated, providing instruction on new protocols, regulations, and procedures when necessary. Acting as the liaison between PNM, other LAC departments, and provider accounts, this position aims to efficiently address complex situations while delivering relevant, timely, and accurate information. Additionally, assistance is provided in organizing scheduled meetings with providers or provider groups, including conference calls and site visits. The role also translates ideas, requests, and information-sharing into actionable steps to enhance relationship and contract management, along with better service delivery. It involves examining operational, contractual, and payment issues, as well as communicating new guidelines, rules, and practices to providers. Furthermore, verification of the provider database and documentation is essential to ensure accuracy, completeness, and currency. Support is provided to data management, operations, oversight, and monitoring within LAC PNM departments. Contributions are made to the development and distribution of provider engagement materials, such as newsletters, notices, and training sessions. Assistance with tracking activities and implementing LAC provider initiatives also forms part of the role. Improving the quality of provider data is a priority. Help is provided with claim-related issues, including the creation of JIRA tickets and claim intake for both Vendor and Ancillary Teams, support to the Legal team with Letter of Interest Appeals, development of HDO credentialing applications for Vendor Management and Ancillary. Also, assistance Finance Department with payment inquiries. Additionally, collaboration with account managers on projects.
Provider Service Unit III
7 Years- Responsibilities included assisting providers with detailed claims, obtaining authorizations, managing appeals, negotiating contracts, creating accounts for web portals, and participating in initiatives like emergency disaster recovery and new system testing. The role also involved providing support to individuals and collaborating with other departments on various projects.
- The services offered to both providers and members encompassed Business Lines such as MCLA, PASC, CMC, LACC, and LACD. Assistance was given to existing clients as well as prospective ones. This included responding to inquiries via emails and calls from members and providers. Payment processes for members were facilitated, and member portals were developed. Furthermore, communication with members was maintained through email responses, and concerns from members were effectively managed. Members received detailed coverage information and assistance with modifications to their primary care providers, along with obtaining authorizations and making demographic adjustments.
Rep Member Services II
2 Years 7 Months- Claims Dept.: Assisting providers with their claims and contracting inquiries, as well as Market Place Plans and Medicaid Plans All State, were among the duties involved. Provider services include billing inquiries, pharmacy claim inquiries, grievance and appeals processing for all states, and more. Helped the providers with escalated calls regarding contracts and claims for every state and company category.
- Handles and drafts written responses to provider reconsideration requests that come in regarding the payment of claims, requests for claim changes, or requests from other organizations.
- Looks at provider contracts, pricing schedules, system configurations, and standards for processing claims to identify the main source of payment errors.
- Spots possible issues with providers by using a proactive strategy that involves trending and mining data to find and stop trouble areas with providers.
- Researches and prepares healthcare provider data using a range of references to load it into the health plan system or database; inserts provider demographics, contract affiliation, or other data as required.
- Communicates with various departments on issues pertaining to provider configuration and other pertinent provider matters.
- Compiles all correspondence and appeal data precisely and succinctly, adhering to regulatory standards.
- Keeps track of correspondence and results; keeps all appeals' files thorough, accurate, and well organized.
- Keeps an eye on every request to make sure all internal and legal deadlines are fulfilled. In charge of submitting, addressing, and resolving appeals, grievances, and/or complaints from Molina members and associated external organizations.
- Investigates problems and makes decisions about health care services and member care using systems, clinical assessment expertise, knowledge, and authorized "Decision Support Tools."
- In accordance with protocol, formulates conclusions and works with Medical Directors and other team members to determine the appropriate course of action. Requests and reviews medical records, notes, and/or detailed bills as needed. Ensures that responses are appropriate and timely in accordance with state, federal, and Molina Healthcare guidelines.
- Assists in creating narratives, graphs, flowcharts, and other visual aids for presentations and audits; composes appeal summaries, correspondence, and records information for tracking/trending statistics.
- Present Representative Member Services II - Department of Claims at Molina Healthcare. Having established relationships with suppliers for more than a decade, the individual is fearless, industrious, and amiable. Thrives in hectic, productive work environments and has exceptional creative problem-solving skills. Enjoy collaborating with people and seeing projects through to completion.
Education
Associate of Arts - Administration To Justice
Skills
Applied extensive public relations and administrative support experience across several years in professional environments.
Maintained advanced proficiency in Microsoft Office
Messenger
QNXT
CCA
SyntraNet
DataNet
StrataFax
Office Ally
DocuSign
KPI
DRT
and CRM systems.
Drove department quality and production targets through accurate execution of assigned work.
Directed contract routing for new providers
processed vendor invoices for payment
and coordinated related administrative workflows.
Partnered with account managers to address claim issues
managed provider relations
CRM
provider reporting
PNM letters of interest
IDT cases
and term providers inboxes
produced PIFs and exhibit Gs for ABA providers
and prepared DocuSign and Therefore reports for routed contracts.
Handled tracers
supported provider questions on claims
eligibility
benefits
and payment status
assisted with claims processing
billing concerns
and clinical authorization requests
and maintained daily provider communication for network engagement.
Languages
English
Full Professional
Spanish
Full Professional
Timeline
Provider Network Management Coordinator II
LA Care Health Plan
08.2024 - CurrentRead More
Provider Service Unit III
08.2017 - 08.2024Read More
Rep Member Services II
Molina HealthCare
01.2015 - 08.2017Read More
Glendale Community College
Associate of Arts from Administration To Justice
Read More