Rosa Delgado
Casa Grande,AZ
Summary
Working in the client service, financial, and medical sectors has allowed me to unlock several opportunities for advancement and seniority acquisition by showcasing the ability to adapt and assess organizational challenges while simultaneously providing solutions.
Overview
8
8
years of professional experience
Work History
Lead Auditor
Evolent/Magellan
11.2021 - Current
- Provides training and development of staff and participates in operational activities to meet state specific service level agreements related to appeals and grievances.
- Assists and educates operational staff with problem-solving and resolving tenuous situations to the best possible outcomes
- Oversees the adherence to required turnaround times set by each health plan to meet state accreditation requirements and performance guarantees.
- Assists Director of Appeals in monitoring activities of the Appeals & Grievances unit by developing and delivering weekly, monthly, and quarterly regulatory reports.
- Leads and standardizes appeals policies/procedures and updates as directed by state requirements.
- Assumes responsibility for self-development and career progression
- Proactively seeks and participates in auditing, coaching, and training (formal and informal) in all aspects of the Appeals Coordinator role.
- Developed workflows and innovative process improvements to make a positive impact department-wide.
- Implements and directly oversees process improvements to achieve operational effectiveness and efficiencies.
- Facilitates and prepares field medical directors to provide testimony on behalf of the health plan in an administrative state fair hearing.
- Communicates directly with account management and clients to ensure state accreditation requirements are met.
Appeals Senior Coordinator
Magellan
07.2020 - 11.2021
- Analyzed and rendered final decisions of non-clinical appeals according to procedure, state and federal guidelines, benefit plan guidelines, company internal policies and workflows.
- Coordinated the appeal and dispute process through the collection of clinical records and consultation with Physician Advisors/Medical Directors and communicating the final determination.
- Responsible for maintaining a productive interface with members and providers as required in terms of status, process and outcomes of complaints and appeals.
- Maintained the integrity of the company relationship with customers by researching, resolving and responding to customer inquiries for appeals, disputes and scheduling issues.
- Assisted with managed risk situations that entailed consulting with senior management and rendering determinations that could avoid adversely affecting the company.
- Researched, compiled, and consulted with external review organizations and customers as necessary for appeals and complaint processes.
- Contributed to unit and department CQI (continuous quality improvement) processes by participating in unit goal setting, scorecard development and departmental meetings
- Consulted with internal departments such as Clinical, Legal, and Network, as well as company senior management to assure appeal and complaint decisions meet all guidelines and result in customer satisfaction when possible.
Appeals Coordinator
Magellan
07.2019 - 07.2020
- Maintained a caseload and monitored day to day compliance of appeal decision time frames.
- Reviewed clinical and medical records for completeness and determined administrative or clinical appeal.
- Assigned reviews to physician advisers and medical directors for those requiring medical necessity reviews.
- Participated in data gathering and analysis of reports regarding appeal activity as well as preparing for appeals audits, provided new employee training, monitored QI (Quality Improvement) activities of the appeals department, and assisted in the development of depart flows and implementations.
- Consulted with managers on problem cases and interfaces with case managers, clinical supervisors, account managers and other personnel in resolving denial and appeal questions.
- Responded to member, provider, and client telephone inquiries regarding status, process and outcome of appeals.
- Organized volume of work and work-flow so that performance standards and proper procedures for appeals resolution according to client requirements and state and federal regulations are addressed.
Customer Service Representative
McKesson
11.2017 - 06.2018
- Oversaw the educating patients, healthcare providers and advocates about medication convergence assistance with several patient assistance foundations.
- Processed drug authorizations and communicated with McKesson Specialty Health Pharmacy about patient medications.
- Established and maintained point of contact relationships with pharmacy technicians, healthcare providers advocates, and MDs.
- Partook in extensive data entry of patient medical history.
- Provided healthcare information as it pertains to the applicant’s financial and medical situations.
Transfer Agent
Computershare/Adecco
07.2017 - 11.2017
- Responsible for ensuring excellent customer service by offering stock services to shareholders with relation to accounts in a wide arrangement of companies and businesses.
- Provided up to date and accurate information by utilizing knowledge of internal systems to communicate information to customers.
- Researched account and transaction information and record to resolve account issues and basic discrepancies.
- Managed stock portfolios ranging from $10,000 to $1,000,000+.
- Communicated on a daily basis with stock brokers and financial advisors for Fortune 500 companies.
Education
Masters of Arts - Communication
Arizona State University
01.2024
Bachelors in Applied Science - undefined
Arizona State University
01.2017
Associates - Forensic Technology
Phoenix College
01.2015
High School Diploma - undefined
Independence High School
01.2013
Skills
- Communication
- Leadership
- Training & Development
- Auditing
- Policy and Procedural Writing
- Bilingual - Spanish
- Project Management
- Innovation
- Software Efficiency
- Adaptability
- Problem Solving
- Self-sufficiency
LANGUAGES
Spanish
English
Timeline
Lead Auditor
Evolent/Magellan
11.2021 - Current
Appeals Senior Coordinator
Magellan
07.2020 - 11.2021
Appeals Coordinator
Magellan
07.2019 - 07.2020
Customer Service Representative
McKesson
11.2017 - 06.2018
Transfer Agent
Computershare/Adecco
07.2017 - 11.2017
Masters of Arts - Communication
Arizona State University
Bachelors in Applied Science - undefined
Arizona State University
Associates - Forensic Technology
Phoenix College
High School Diploma - undefined
Independence High School
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