Sam Proeung
Regulatory Complaint Coordinator
Ione,CA
Summary
To obtain a position where I can make use of my three years as an Appeals and Grievances Coordinator, Senior, and four years as a Regulatory Complaint Coordinator, 15+ years of customer service, and conflict resolution to make an immediate and substantial contribution towards your company's mission and vision.
Overview
10
10
years of professional experience
1
1
Certification
Work History
Regulatory Complaint Coordinator
Blue Shield of California
01.2020 - Current
- Assist with training and development of new hires.
- Prepare detailed file summary responses for submission to multiple regulatory, legislative, and accreditation agencies.
- Be involved in evaluating and researching end-to-end timelines of member health provider services, claim processing, and other data to determine decision and/or alternative ways to resolve grievance/appeal.
- Respond to the most complex and highest financial and/or goodwill impact regulatory complaint inquiries.
- Research the data files and develop a timeline of events and gather missing information from third parties such as medical providers, to determine the response to the inquiry.
- Respond to correspondence addressed to highest level executives regarding issues and/or concerns that an individual (member or non-member) may have.
Appeals and Grievances Coordinator-Senior
Blue Shield of California
01.2018 - 01.2020
- Assist with training and development of new hires.
- Facilitate chair-siding with employees not meeting production or quality metrics.
- Ensure all 30-day cases are closed by close of business day.
- Meet or exceed production levels of eight cases per day.
- Maintain quality metrics of 97% or higher.
Appeals and Grievances Coordinator-Intermediate
Blue Shield of California
01.2017 - 01.2018
- Receive, document, investigate, refer, and coordinate grievances, appeals and complaints.
- Initiates case files for each grievance and ensures compliance with organizational and regulatory requirements.
- Triage all cases within 15-days of receipt to identify possible clinical cases needing reassignment, verify correct use of case codes.
- Submit sign-off requests to leadership for high dollar claims.
- Meet or exceed quality standards of 95% and above.
- Maintain daily production of 6 cases per day.
Customer Care/Claims Representative
Blue Shield of California
01.2015 - 01.2017
- Resolve BSC members’ phone inquiries and provide world class customer service.
- Meet or exceed performance metrics in schedule adherence, and customer surveys.
- Ability to communicate with internal and external customers to properly educate and engage necessary departments to provide one call resolution and increase customer satisfaction.
Education
A.S. - Business Software Application
Heald College
Stockton, CA01.2002
Skills
- Advanced knowledge of MS Office software programs
- Expert with all Blue Shield of California programs ie, Rad, MD, Med Hok, CVS Pharmacy
- Highly experienced at investigating and resolving complex cases Outstanding analytical skills and coming to a resolution
- Engaged with Blue Shield of California (BSC) private policy program to ensure BSC is in compliance with the Department of Manage Health Care (DMHC)
- Advanced communication, negotiation, and conflict resolution skills
- Identify, escalate, and report priority issues to leadership according to policies, procedures, and ensure members’ Health Insurance Portability and Accountability Act (HIPAA) remains protected
- The ability to work independently and in a team environment with little to no direct supervision
- Dependability, to follow instructions as well as take responsibility for actions and keep commitments Punctuality and a strong work ethic
Certification
ISO 9001 Auditor
Languages
Cambodian
Elementary
Timeline
Regulatory Complaint Coordinator
Blue Shield of California
01.2020 - Current
Appeals and Grievances Coordinator-Senior
Blue Shield of California
01.2018 - 01.2020
Appeals and Grievances Coordinator-Intermediate
Blue Shield of California
01.2017 - 01.2018
Customer Care/Claims Representative
Blue Shield of California
01.2015 - 01.2017
A.S. - Business Software Application
Heald College
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