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
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