Summary
Overview
Work History
Education
Skills
References
Leadership Experience
Communication Skills
Timeline
Generic

Rosario L. Patron

La Puente,CA

Summary

Driven by Professional results with over 15 years of Enrollment & Reconciliation experience. I am Professional leading and directing large operational teams. Sound business acumen to include financial management, business development, short / long-term strategic planning, and project management. The track record of leading high-performance teams known to deliver surpassing qualitative and quantitative metrics, exceptional service, and advancement of top-level objectives with cost and time management efficiency. Excellent team building and professional development skills. Strong leadership skills and ability to relate to all levels of management and staff as well as external entities.

Overview

19
19
years of professional experience

Work History

Program Manager

Molina Healthcare Inc.
12.2023 - Current
  • Highly motivated experienced Program Manager (Medicare) responsible for the coordination and maintenance of Molina’s regulatory agencies such as the Centers for Medicare & Medicaid Services (CMS) and the Department of Healthcare Services (DHCS).
  • Manage projects and other assignments in the Regulatory Affairs & Compliance (Medicare) department, including those relating to department efficiency to ensure department objectives and initiatives are met.
  • Completed a variety of detailed analyses, including the assessment of the impact of state and federal regulatory changes in M360 Medicare system.
  • Interact with Molina leadership, and state and federal regulatory agencies. Support other IT/ Projects staff on related projects.
  • Comprehensive knowledge of presentation development, and the ability to communicate complex ideas in a simple and understandable fashion.
  • Work confidently and competently in a matrix environment with multiple stakeholders and clients. Strong communication skills, both verbal and written, to communicate effectively at all levels of the organization.
  • Experience translating short- and long-range business plans to internal subject matter experts to aid them in assembling strategic H-plans.
  • Ability to recognize and resolve conflicts through collaboration, communication and customer (patient and physician) advocacy.
  • Provide input to market research, including competitive benchmarking and audience studies used to inform decisions regarding customer targeting.
  • Strong relationship building and bridging competencies.
  • Work on the 834 Business rules with Wipro M360.

MPSS AR Manager, Premium Billing

LA Care Health Plan
09.2018 - 12.2022
  • Responsible for management and oversight of the staff responsible for the preparation of all month end financial activity reports.
  • Manage the staff who perform the monthly review and provide detailed explanations of variance reports to support trends.
  • Manages the staff who are responsible for ensuring all scheduled Healthcare cash disbursements are issued accordingly and reconciled to Solomon through month end closing processes.
  • My team provides ad Hoc analysis to support operational requests as they relate to the product lines and/or implemented pilot contracts with participating physician groups (PPGs), hospitals and ancillary providers.
  • Work very closely with other departments to coordinate reporting requests and ensure a complete understanding of variances to be documented. Hire, train and manage supporting staff.
  • Responsible for the reconciliation process to ensure all monthly variances are clearly defined and accurately prepared for all Line of Business. Manage and direct staff responsible for Ad-hoc reports requests ensuring proper prioritizing, delegation and coordination with customers.
  • Manage and directs the staff performing the weekly cash disbursement process to ensure timeliness regulatory requirements.
  • Manages and directs the staff responsible for the monthly process to ensure reconciliation process to Solomon and file creation process is accurate. Manage the training of the various reporting tools to ensure a full understanding of the staff.
  • Worked cohesively with other department to maintain policies/governs CMS, DMHC, MediCal and Medicare standards quality and accuracy including Fraud, Waste, and Abuse monitoring.

Manager, Medicare & Reconciliation

Care1st Health Plan
05.2015 - 06.2018
  • Maintained medium to large scale projects, including documentation of project proposal, project scope, project plan, timelines and reporting.
  • Managed day-to-day workflow activities necessary to maintain efficient and effective membership processing and reconciliation for the Medicare line of business, while ensuring adherence to all applicable state and federal regulatory standards.
  • Ensured the Medicare Department is the subject matter experts, assures the accuracy of the membership data systems, financial reconciliation for internal/external reporting.
  • Developed approach to effectively analyze, interpret, communicate and apply regulatory documents.
  • Oversee and approve the work output of other plans and corporate analysts and staff to ensure compliance.
  • Develops the Medicare Advantage policies/procedures for the Quality Improvement Program, workplans, and program descriptions as assigned for plan implementation.
  • Analyze, apply, interpret and communicate policies, procedures and regulations effectively to meet regulatory requirements.
  • Oversee resolution on grievance & appeals for the Medi-Medi membership.
  • Implementation of updates, Medicare related QI Policies, QI training materials, QI Program document template, and QI Program working documents.
  • Participates and makes Plan recommendations for process improvements in work organization, communication and efficiency with internal and external customers.
  • Created annual goals, objectives and budget and made recommendations to reduce directed installation of improved work methods and procedures to achieve agency objectives.
  • Ensured the accuracy of public information and materials.
  • Actively maintained up-to-date knowledge of applicable state and Federal laws and regulations.
  • Worked with state clients and stakeholders to shape procurement's and identify opportunities for value added services.
  • Minimized staff turnover through appropriate selection, orientation, training, staff education and development.
  • Conduct on-going monitoring of quality assurance processes by running system reports, conducting trouble shooting and providing feedback to committees, Plan Leadership, Medicare Operations and Vice President.

Manager, Data Management

Citrus Valley Health Partners
05.2013 - 10.2016
  • Accomplishes data resource objectives by recruiting, selecting, orienting, training, assigning, scheduling, coaching, counseling employees; communicating job expectations; planning, monitoring, and reviewing job contributions; planning and reviewing compensation actions; enforcing policies and procedures.
  • Achieves data operational objectives by contributing information and recommendations to strategic plans and reviews preparing and completing action plans; implementing production, productivity, quality, and customer-service standards; resolving problems.
  • Meets Data objectives by forecasting requirements; preparing and scheduling expenditures; analyzing variances; initiating corrective actions.
  • Determines Data service requirements by conducting surveys; forming focus groups; benchmarks best practices; analyzing information and applications.
  • Accomplishes day-to-day work operations by initiating, coordinating, and enforcing Data policies and procedures.
  • Improves Data quality results by completing audits; identifying trends; determining system improvements; studying, evaluating, and re-designing work processes; implementing changes.
  • Updates job knowledge by participating in educational opportunities; reading professional publications; maintaining personal networks; participating in professional organizations.
  • Supervised and evaluated the activities of medical, nursing, technical, clerical, service, maintenance and other personnel.
  • Analyzed facility activities and data to properly assess risk management and improve services.
  • Evaluated nursing notes to confirm that they accurately and completely described the care provided and patient responses.

Manager, Medicare Membership

SynerMed
12.2011 - 10.2013
  • Responsible for all Medicare related processes, which includes increasing senior enrollment, retention of current membership, lowering dis enrollments, contacting current non-Medicare members about to “age-in,” facilitating annual physical exams/health risk assessments for all senior members, and liaison to all internal departments and remote branch locations.
  • Act as liaison with branch locations for managing relationships with outside Brokers/Agents assigned to write up Medicare business.
  • Responsible for directly overseeing the day-to-day operation within the Medicare Member Advocate service unit, including supervision of personnel and monitoring of all incoming and outgoing calls to ensure quality standards.
  • Aid in the creation and implementation of the policies and procedures pertinent to the running of the unit.
  • Organize and maintain medium to large scale projects, including documentation of project proposals, project scope, project plan, timelines and reporting.
  • Develop approach to effectively analyze, interpret, communicate and apply regulatory documents.
  • Prepare membership reports and presentations for management, committees and external organizations as required.
  • Oversee and approves the work output of other plans and corporate analysts and staff to ensure compliance with requirements.
  • Participates and makes Plan recommendations for process improvements in work organization, communication and efficiency with internal and external customers.
  • Monitored and audit staff on Customer Service/Compliance.
  • Planned and executed operational audits of various business areas using risk-based audit methodology.
  • Tested the design and effectiveness of internal controls by completing walkthrough of complex business processes.
  • Diligently monitored remediation plans to confirm proper resolution. Completed regulatory, pre-implementation and risk-based audits to achieve business objectives.

Manager, Medicare Operations

SCAN Health Plan
10.2010 - 12.2011
  • Responsible for overseeing Enrollment and Dis-enrollment processing, review, and identifies areas of membership eligibility.
  • Manage and oversee auditing processes and identify improvement opportunities.
  • Maintains policies/governs CMS, DMHC, MediCal and Medicare standards quality and accuracy including Fraud, Waste, and Abuse monitoring.
  • Support reconciliation requirements for Medicare membership enrolled in a government program.
  • Manage CMS regulations, all Medicare Marketing Materials, MA/PDP plans.
  • Manage day to day Medicare Advantage operational issues and facilitate resolution if applicable and provide staff with clear direction and guidance in making accurate determinations and addressing system or workflow concerns.
  • Develop the Medicare Advantage policies/procedures for the Quality Improvement Program, including charters, work-plans, and program descriptions assigned for plan implementation.
  • Able to analyze, apply, interpret and communicate policies, procedures and regulations effectively to meet regulatory and accreditation requirements.
  • Verified that company controls were in compliance with established policies by auditing stores and warehouses.
  • Systematically prepared documents and assembled an enrollment universe for independent auditors.
  • Oversee implementation of updates and oversee Medicare related QI Policies, QI training materials, QI Program document template language and QI Program working documents.
  • Served as mentor to junior team members. Increased profits by developing, initiating, and managing MSP.
  • Identified inefficiencies and made recommendations for process improvements. Designed promotional materials.
  • Forecast needs and adjusted future plans.

Manager, Membership Accounting

Molina Healthcare Inc.
02.2006 - 10.2010
  • Responsible for overseeing Enrollment and Dis-enrollment processing, review, and identify areas of membership eligibility.
  • Manage and oversee auditing processes and identify improvement opportunities.
  • Maintains policies/governs CMS, DMHC, MediCal and Medicare standards quality and accuracy including Fraud, Waste, and Abuse monitoring.
  • Support reconciliation requirements for Medicare membership enrolled in a government program.
  • Manage CMS regulations, all Medicare Marketing Materials, MA/PDP plans.
  • Manage day to day Medicare Advantage operational issues and facilitate resolution if applicable and provide staff with clear direction and guidance in making accurate determinations and addressing system or workflow concerns.
  • Develop the Medicare Advantage policies/procedures for the Quality Improvement program, including charters, work-plans, and program descriptions as assigned for plan implementation.
  • Able to analyze, apply, interpret and communicate policies, procedures and regulations effectively to meet regulatory and accreditation requirements.
  • Verified that company controls were in compliance with established policies by auditing stores and warehouses.
  • Systematically prepared documents and assembled an enrollment universe for independent auditors.
  • Oversee implementation of updates and oversee Medicare related QI Policies, QI training materials, QI Program document template language and QI Program working documents.
  • Served as mentor to junior team members. Increased profits by developing, initiating, and managing MSP.
  • Identified inefficiencies and made recommendations for process improvements. Designed promotional materials.
  • Forecast needs and adjusted future plans.

Education

BA - Business Administration

Capella University

Skills

  • Collaboration
  • Adaptability
  • Team Leadership
  • Strategic Planning
  • Compliance Planning
  • Implementing Procedures
  • Communication Support
  • Time Management
  • Problem-solving

References

Available upon request.

Leadership Experience

I have successfully led teams to exceed their goals and have the ability to showcase integrity, build rapport, problem solver, innovator, dependable, teach and mentor, and very analytical decision making.

Communication Skills

Customer Service with professional communication and transparency with the ability to inspire others. Implemented new procedures and technologies that improved efficiency and streamlined operations.

Timeline

Program Manager

Molina Healthcare Inc.
12.2023 - Current

MPSS AR Manager, Premium Billing

LA Care Health Plan
09.2018 - 12.2022

Manager, Medicare & Reconciliation

Care1st Health Plan
05.2015 - 06.2018

Manager, Data Management

Citrus Valley Health Partners
05.2013 - 10.2016

Manager, Medicare Membership

SynerMed
12.2011 - 10.2013

Manager, Medicare Operations

SCAN Health Plan
10.2010 - 12.2011

Manager, Membership Accounting

Molina Healthcare Inc.
02.2006 - 10.2010

BA - Business Administration

Capella University

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