Raquel Rivera
Health Coach
New Britain,CT
Summary
Proven expertise in conducting in-depth audits and devising successful quality improvement strategies. Methodically evaluated patient outcomes and initiated clinical health outcomes in compliance with NCQA standards. Superb analytical and communications skills enabled optimum results.
Overview
11
11
years of professional experience
Work History
Audit Coordinator
NEIS
Cheshire, CT
07.2016 - 10.2017
- Performed detailed analysis of accounts payable and receivable ledgers to ensure accuracy of transactions.
- Prepared audit reports outlining findings and recommendations for corrective action.
- Reviewed documents such as contracts, leases, tax returns, insurance policies, and other financial statements.
- Provided guidance on best practices related to internal control systems design, implementation, monitoring, testing, reporting requirements and documentation standards.
Patient Care Advocate
WellCare Health Plans Inc.
Hamden, CT
06.2020 - 08.2023
- Facilitated monthly meetings with the interdisciplinary team to discuss complex cases and develop holistic plans of action.
- Facilitated communication between physicians, nurses, social workers, family members, and other stakeholders in the patient's care..
- Participated in quality improvement initiatives aimed at improving overall patient experience.
- Maintained current knowledge of relevant laws, regulations, policies, procedures, standards of practice related to patient advocacy.
Sales Assistant
WellCare Health Plans Inc.
Hamden, CT
05.2018 - 06.2023
- Completed daily reports on sales performance metrics such as plans sold per day, week, month.
- Responsible for front desk duties, such as answering phones, sending mail and retrieving packages.
- Collaborated with other departments such as marketing, merchandising, operations, to ensure smooth functioning of overall sales operations.
- Tracked inventory levels using various systems and restocked supplies accordingly while performing front desk
- Facilitated training and on-boarding for new employees on proper use of equipment and software applications related to sales activities.
HEDIS Service Associate Pursuit
Anthem
Wallingford, CT
01.2016 - 05.2016
- Gathered, evaluated and interpreted data from various sources to ensure accuracy.
- Identified potential areas of improvement in provider performance related to HEDIS measures.
- Reviewed medical records for completeness, accuracy, timeliness, and appropriateness of care.
HEDIS Associate Pursuit
Anthem
Wallingford, CT
01.2016 - 05.2016
- Seasonal position. Generated detailed reports on findings related to HEDIS standards.
- Compiled statistical reports summarizing audit results for management review.
- Analyzed data to identify trends and patterns that may impact quality metrics.
- Participated in training sessions aimed at increasing understanding of HEDIS protocols.
Administrative Care Coordinator
Community Health Network Of Connecticut
Wallingford, CT
03.2012 - 03.2015
- Completed administrative tasks for five RN case managers. Triaged and assessed complex co-morbid members for case management.
- Provided case management services for pregnant, diabetic and asthmatic members to ensure the delivery of quality care.
- Facilitated referrals to community resources such as housing, transportation, employment opportunities.
- Ensured compliance with state regulations related to healthcare service provision.
- Established solid relations with leadership and staff by attending board meetings and coordinating interdepartmental information exchanges.
Education
Bachelor of Science - Health Administration & Management
Colorado State University
Aurora05.2019
High School Diploma -
Middletown High School
Middletown, CT06.2006
Skills
- Records Review
- Risk Management
- Critical Thinking and Analysis
- Non-Compliance Assessment
Timeline
Patient Care Advocate
WellCare Health Plans Inc.
06.2020 - 08.2023
Sales Assistant
WellCare Health Plans Inc.
05.2018 - 06.2023
Audit Coordinator
NEIS
07.2016 - 10.2017
HEDIS Service Associate Pursuit
Anthem
01.2016 - 05.2016
HEDIS Associate Pursuit
Anthem
01.2016 - 05.2016
Administrative Care Coordinator
Community Health Network Of Connecticut
03.2012 - 03.2015
Bachelor of Science - Health Administration & Management
Colorado State University
High School Diploma -
Middletown High School
Similar Profiles
DANIEL SOMMERVILLEDANIEL SOMMERVILLE
Quality Review and Training at NEISQuality Review and Training at NEIS
Corey PageCorey Page
Premium Auditor at NEISPremium Auditor at NEIS
Jessica AyalaJessica Ayala
Call Center Audit Rep at NEISCall Center Audit Rep at NEIS