Patricia Hall
Rancho Cordova,CA
Summary
Clinical healthcare professional with strong background in coordinating patient care and managing clinical operations. Skilled in team collaboration, ensuring seamless communication among staff, and adapting to evolving healthcare needs. Proven expertise in workflow optimization, patient scheduling, and compliance with medical regulations. Known for fostering supportive environment and delivering high-quality results.
Overview
32
32
years of professional experience
Work History
Clinical Coordinator
Blue Shield of California
01.2020 - Current
- Request medical record and/or response request from provider regarding identified quality issues
- Manage and review incoming medical records/responses and collaborate with CQR Nurses
- Research provider and member information using internal applications (Facets, PR Card, appeals, claims, customer service)
- Establish and maintain relationships with hospitals, IPAs/Medical Groups, and providers for follow-up, authorizations, medical records and supporting documentation
- Provide guidance and assistance to entry level team members (train, mentor, act as resource)
- Knowledge of regulatory and accreditation agencies and managed principals and benefits (DMHC, CMS, NCQA)
Grievance/Appeal Coordinator
Blue Shield of California
01.2012 - 01.2020
- Research, review and resolve high level/high priority members’ grievances, appeals, and complaints while clarify issues and educating customers on health plan benefits, policies, and procedures
- Coordinate next level grievance/appeal meeting with appropriate parties and compile medical records and other supporting documentation for review
- Produce complex written correspondence to resolve members’ grievances, appeals, and complaints
- Maintain cohesive relationship with IPA, MHSA, NIA Pharmacy partners through telephone and written communication
- Collaborate with RN/MD while grievance/appeals are under review for all medical and pharmacy cases
- Generate prior authorizations and monitor the authorization platform to ensure proper implementation.
- Interpret and explain health plan benefits, polices, procedures and function of medical and pharmacy benefits to members and providers.
Senior Operations Processor
Blue Shield of California
01.2008 - 01.2012
- Maintain provider files for Individual, Group, and IPA requests for BSC and TRICARE
- Performed senior functions created Facilities, Ambulatory Surgery Center Home Health, Home Infusion, DME, Medical/Allied Groups/IPAs, Skilled Nursing, Dialysis and Diagnostic Lab records
- Contracted with MD, medical groups, and Allied providers
- Collaborated with internal departments resolved complex issues
- Understanding of PPO contract language and claims payment procedures
- Knowledge of regulatory and accreditation agencies (DMHC, DHCS, CMS)
Senior Trainer/Auditor
Blue Shield of California
01.1999 - 01.2008
- Provided education and direction to training team
- Created training materials and instituted training
- Collaborated with the auditor to establish training needs
- Audited work to ensure quality and production standards were met
- Provided feedback to management on current inventory levels
- Implemented new training criteria and tacking tools
- Designed workflows, guidelines and policy used in department
- Provided guidance and support to the team by using the leadership development skills to enhance team development
- Knowledge of managed care principles and benefits plans per line of business (HMO, PPO, Medicare)
- Managed various projects including: NPI Project, File Clean Up Project, Provider Allowances, CalPERS Narrow Network Expansion
Provider Services Representative
Blue Shield of California
01.1998 - 01.1999
- Resolved provider inquiries by telephone and correspondence
- Analyzed claims to resolve complex issues
- Knowledge of contract language and claims payment procedures
- Researched and provided resolution for inquiries regarding claims
- Prepared cases for medical review and case management
Finance Manager
Chiropractic Health Centre
01.1996 - 01.1998
- Administered billing and collections to settle outstanding accounts
- Obtained patient’s prior authorization for care management with Medical Insurance Personal Injury, Workmen Comp cases
- Managed Medical billing, authorizations, treatment plans
- Conducted weekly statistical reports, payroll, and administrative functions
- Performed audits, analyzed denials, reviewed claims and made adjusts to accounts
- Assisted front and back function of the office
Senior Customer Service Representative
Gallagher & Bassett
01.1994 - 01.1996
- Supervised customer service department and other department as required.
- Tracked weekly, biweekly, and monthly reports to ensure personnel meet department goals
- Assisted providers and subscribers and billing/collection departments to settle outstanding accounts
- Verified, setup, and updated eligibility
- Researched and resolved member grievances, appeals and complaints, interprets and explains health plan benefits, policies and procedures to members
- Administered ongoing grievance tracking, trending and reporting for assigned grievances
Education
Skills
- Healthcare Operations
- Provider Certifications & Accreditation
- Benefits and claims processing and grievance/appeal process
- Member Authorizations
- Coordinations of Care
- Knowledge of the BSC proprietary systems and Microsoft applications
- Clinical Case Management
- Developing training programs
Timeline
Clinical Coordinator
Blue Shield of California
01.2020 - Current
Grievance/Appeal Coordinator
Blue Shield of California
01.2012 - 01.2020
Senior Operations Processor
Blue Shield of California
01.2008 - 01.2012
Senior Trainer/Auditor
Blue Shield of California
01.1999 - 01.2008
Provider Services Representative
Blue Shield of California
01.1998 - 01.1999
Finance Manager
Chiropractic Health Centre
01.1996 - 01.1998
Senior Customer Service Representative
Gallagher & Bassett
01.1994 - 01.1996