Summary
Overview
Work History
Education
Skills
References
Timeline
Generic

Priscilla Herrera

Woodland Hills,CA

Summary

Healthcare professional, with years of managed care, administrative, analytical, and customer service experience searching for a position where I can use my leadership and analytical skills to solve complex problems and contribute to the success of the organization.

Overview

8
8
years of professional experience

Work History

Senior Appeals and Grievances Coordinator-Expedited (EXR) Team

Health Net
Woodland Hills, CA
12.2022 - Current
  • Research, resolve, and respond to all expedited/high risk member and provider inquiries of various lines of businesses within 24-72 hours
  • Profound knowledge of Commercial, State Health Programs, and Medicare lines of business
  • Accountable for managing assigned cases and provide full investigation of all issues
  • Lead in problem solving and coordination of efforts between with a diverse set of internal/external business units to achieve the best results in grievance handling
  • Serve as lead in multiple special projects including OBC Audit Review through Excel, Training new hires and auditing their case work
  • Work as lead in complex, high risk DMHC/CDI cases with the Regulatory Team and the Legal Department
  • Tracked member/enrollee complaints against internal departments, including Customer Contact Center and Claims, and prepared course of action plans to prevent further incidences from occurring
  • Prepared resolution/determination letters or written correspondence addressing member's complaints and/or concerns.

Appeals and Grievances Coordinator-Clinical Team

Health Net
Woodland Hills, CA
03.2018 - 12.2022
  • Researched, resolved, and responded to both HMO and PPO member/enrollee complaints and educated members on their eligibility and benefits
  • Initiated effectuation requests for overturned claims and for medical, pharmacy, and mental health authorizations overturned by department's medical director
  • Prepared resolution/determination letters or written correspondence addressing member's complaints and/or concerns
  • Investigated member/enrollee complaints against vendors, participating, nonparticipating providers, and assisted members in locating a new Primary Care Physician and/or medical group if requested
  • Requested medical records, determination letters, authorization requests, and written response from member's medical group and/or provider(s) for clinical cases prior to forwarding to medical director for determination.

Appeals and Grievances Administrative Assistant

Health Net
Woodland Hills, CA
11.2017 - 03.2018
  • Initiated intake for incoming appeals and grievances received via fax, mail, and email
  • Triaged, and prioritized, cases for clinical urgency or to meet deadline guidelines set by CMS for Medicare and Medi-Cal and DMHC or DOI regulations for commercial lines of business
  • Provided administrative support to ensure efficient operation of office
  • Handled sensitive incoming medical records and assisted in routing to the appropriate coordinator
  • Served as liaison between Appeals & Grievances and other departments at Health Net primarily Customer Service and Broker/Sales Account Management
  • E.g
  • Provided internal associates with status of existing cases and department processes.

Eligibility Representative Level 2

Health Net
Woodland Hills, CA
02.2016 - 11.2017
  • Maintained accurate eligibility records for assigned line of businesses
  • Entered system eligibility data on a daily basis, including new enrollees, changes, and cancellations
  • Provided project support, new hire training and coordination of open enrollment processing as needed
  • Responded to all written and telephone eligibility inquiries from individuals or assigned employer groups
  • Received Golden Tickets for: assisting other departments, receiving 97% or higher per monthly audits and surpassing monthly production goal.

Education

Associate of Science - Social and Behavioral Sciences

Los Angeles Pierce College

Associate of Science - STEM

Los Angeles Pierce College

Bachelor of Science - Health Administration

California State University of Northridge

Skills

  • Advanced in Microsoft Office including Word, Excel, Outlook, Teams, PowerPoint, and Access
  • Bilingual - Spanish Speaking
  • Strong organizational, communication, and written skills to build effective relationships
  • Strong background in compliance and high-risk DMHC related issues
  • Ability to work independently and as part of a team, flexible, and ability to manage multiple assignments in fast-paced environments

References

Available upon request

Timeline

Senior Appeals and Grievances Coordinator-Expedited (EXR) Team

Health Net
12.2022 - Current

Appeals and Grievances Coordinator-Clinical Team

Health Net
03.2018 - 12.2022

Appeals and Grievances Administrative Assistant

Health Net
11.2017 - 03.2018

Eligibility Representative Level 2

Health Net
02.2016 - 11.2017

Associate of Science - Social and Behavioral Sciences

Los Angeles Pierce College

Associate of Science - STEM

Los Angeles Pierce College

Bachelor of Science - Health Administration

California State University of Northridge
Priscilla Herrera