Rafael Puga
South Gate,CA
Summary
Experienced with managing appeals and dispute resolution processes effectively. Utilizes analytical skills to assess and resolve complex cases while ensuring compliance with regulatory standards. Track record of collaborating with teams to deliver timely and accurate outcomes, adapting to changing needs and requirements.
Overview
27
27
years of professional experience
Work History
Lead CTM & Grievance and Appeal Specialist
Molina Healthcare
Long Beach, CA
10.2020 - 02.2026
- Analyzed DMHC, Medicare and Stare complaints across 20 states contracted with Molina.
- Managed weekly case load, maintaining quality standards for 13 to 20 cases to support operational efficiency.
- Managed resolution of multiple complaints across four urgency levels: urgent, immediate, state DMHC, and standard.
- Ensured accurate documentation of grievance cases to uphold regulatory compliance.
- Analyzed trends in grievances to identify root causes and recommend improvements.
- Conducted root cause analyses to identify patterns in complaints and recommend preventative measures.
- Assisted in creating a centralized database for tracking grievances across multiple departments, streamlining information access for improved efficiency.
- Consistently met performance metrics such as quality scores and case closure rates, demonstrating commitment to excellence in handling customer grievances.
- Improved customer satisfaction by efficiently handling and resolving grievances.
- Effectively communicated case updates to clients, ensuring transparency throughout the resolution process.
Customer Service Center Appeal & Grievance Case Coordinator II
L.A. Care Health Plan
Los Angeles, CA
03.2020 - 10.2020
- Managed weekly case closures, ensuring timely resolution of 60-70 cases to support operational efficiency.
- Conducted comprehensive redetermination reviews for Cal MediConnect (CMC) to ensure compliance with regulatory standards.
- Facilitated expedited pharmacy appeals reviews within a 72-hour time frame.
- Expedited Reviews for all lines of businesses
- L.A. Care Covered California grievances reviews
- Grievance review Billing, Collection
- Intake distribution different lines of Business (Medical, Covered California, Plan partners CMC)
- Plan Partner reviews Kaiser Permanente, Blues Cross, Care First
- Collects, organizes, and tracks information to facilitate and expedite processing of appeals received from a variety of sources.
- Coordinated appeals process, ensuring timely resolution of claims and adherence to regulatory requirements.
- Researched and analyzed case files to determine eligibility for appeals.
- Managed high-stress situations with professionalism, ensuring that appeals were handled promptly and accurately even under tight deadlines or heavy caseloads.
- Educated clients on their rights and responsibilities throughout the appeals process, ensuring a clear understanding of expectations and potential outcomes.
- Managed time efficiently in order to complete all tasks within deadlines.
- Conducted comprehensive claim reviews to determine coverage applicability, policy limits, and appropriate payment amounts.
Appeal & Grievance Case Coordinator I
Health Net
Woodland Hills, CA
01.2015 - 02.2020
- Streamlined information collection, organization, and tracking to enhance appeal processing efficiency.
- Analyzed and addressed administrative components of appeals to ensure compliance with corporate policies and governing regulations.
- Compiled comprehensive case files on member and provider appeals for internal and external review.
- Processes, researches, and resolves provider disputes as assigned.
- Provider Appeals Multiple states
- Supported audit preparation processes for DMHC, URAC, and health plans to ensure compliance.
- Maximus Federal Services Independent Review Entity (IRE)Packets
- Part C, EXR, Part D Experience
- Manage and complete work within established timelines
Customer service Representative II
Health Net
Woodland Hills, CA
09.2012 - 12.2014
- Handled incoming calls to provide customer support and resolve inquiries effectively. Assisted customers with product information and service-related questions. Documented call details to enhance service quality and follow-up procedures.
- Managed data entry activities, maintaining meticulous attention to detail and organization.
- Conducted follow-ups on member claims reprocessing status to enhance operational efficiency.
- Assisted patients with primary care needs. Supported healthcare teams in delivering quality patient care. Facilitated communication between patients and medical staff.
- Assisted in managing transition of care and continuation of care processes by scrubbing and sorting active and invalid requests.
- Oversaw appeals and grievances intake, maintaining accurate records and facilitating timely responses to concerns.
- Managed disenrollment of members, addressing inquiries and ensuring a smooth transition out of the program.
- Managed provider relations initiatives to ensure alignment with organizational goals and improve patient care outcomes.
United State Army Reserves
08.1999 - 01.2008
- Veteran two Foreign War
- Operation Enduring Freedom
- Operation Iraqi Freedom
- National Defense Service Medal
- War on Terrorism Service Medal
- Iraq Campaign Medal
- Mobilized 5 times; awarded 5 medals.
- Graduated Top 5% from Basic Combat training
- Graduated Top 5 % from Advance Individual Training
- Supervised ten man detail
- Processed supply orders
- Transportation driver
- Security transport
- Highest rank Sgt.
Education
Bachelor of Science - Criminal Justice
Westwood College
Torrance, CA05-2011
Skills
- Dependable team player
- Strong communication skills
- Fluent in English and Spanish
- Dedicated problem solver
- Efficient under tight deadlines
Accomplishments
Moved up in promotion in fast period of time
monthly recognized by Supervisor and manager
Timeline
Lead CTM & Grievance and Appeal Specialist
Molina Healthcare
10.2020 - 02.2026
Customer Service Center Appeal & Grievance Case Coordinator II
L.A. Care Health Plan
03.2020 - 10.2020
Appeal & Grievance Case Coordinator I
Health Net
01.2015 - 02.2020
Customer service Representative II
Health Net
09.2012 - 12.2014
United State Army Reserves
08.1999 - 01.2008
Bachelor of Science - Criminal Justice
Westwood College