MONTOYA L. ROGERS

• Utilize consultative sales approach to specified industries to promote CareSource Family of Products and differentiating factors to gain access to their employees for holistic education sessions for all products
• Serve as subject matter expert on CareSource's Medicaid, Health Insurance Marketplace, MyCare and Medicare Advantage lines of business
• Contribute and support development of educational and enrollment opportunities with community and government agencies, community housing, providers and health systems, community business associations, targeted industries, and faith-based organizations
• Effectively coordinate activities with Communications/Marketing, Inside Sales/Member Services, Health Partners, Life Services and Care Management counterparts to ensure achievement of desired results
• Develop and implement territory plan to achieve desired membership and retention goals
• Participate in negotiation, development, and staff coordination of Community/Agency/Provider events.

• Review submitted appeals daily for validation of the appeal
• Complete claim appeal through claim adjustments or letters of denial
• Resolve assigned appeals within regulatory timeframes, achieve department quality expectations, and meet daily production
• Complete External Review packets to submit to Ohio Department of Insurance for review
• Maintain a working knowledge of all products offered under the health plan for multiple states including Ohio, Indiana, Kentucky, and West Virginia
• Conduct detailed research and identify any processing inaccuracies in appeal processing and report findings to Leadership to ensure the accuracy of department processing.

• Analyze and resolve verbal and written claims and authorization appeals from providers
• Pursue resolution of formal grievances from members
• Prepare response letters for member and provider complaints, grievances and appeals
• Maintain files on individual appeals and grievances
• Assists with escalated issues (claims projects/ provider account updates/provider billing)
• Manage large volumes of documents including copying, faxing and scanning incoming mail
• Assist with HEDIS production functions including data entry, calls to provider’s offices, and claims research
• Conduct detailed research and identify any processing inaccuracies in claim payments and route to the appropriate site operations’ team for claim adjustment
• Maintain a working knowledge of all products offered under the health plan.

Provide support services to team members by answering telephone calls, taking messages, researching information and assisting in solving problems

• Assign new enrolled members to the appropriate care manager
• Complete outreach calls to members to complete initial comprehensive assessments
• Send educational material and care plans to members daily
• Develop and maintain a working knowledge of My Care Ohio program
• Assist with creating new policies and procedures for the department
• Maintain accurate and complete documentation of required information that meets disease management regulatory, accreditation, and TQM requirements
• Process service authorizations for Long Term Care and Wavier members in QNXT system
• Manage transfer of data between health plans using Microsoft Excel
• Maintain a working knowledge of all products offered under health plan
• Reviewed claim information in QNXT to determine accurate payment to providers.

• Respond to complex customer calls (80-105 calls per day)
• Answered calls for four lines of business, including Ohio, New York, New Jersey, & Pennsylvania
• Answer and resolved calls from members relating to benefit eligibility information, billing and payment issues, customer material requests, appeals and grievance
• Extensive knowledge and training on My Care Ohio demonstration
• Constantly meet established productivity schedule adherence and quality standards.