Selina Gonzalez
Rosemead,CA
Summary
To seek and maintain full-time position that offers professional challenges utilizing interpersonal skills, excellent time management and problem-solving skills.
Overview
8
8
years of professional experience
Work History
Health Plan Operations Specialist/Credentialing Coordinator
AltaMed/Altura MSO
2021.08 - Current
- Analyze process workflow to eliminate waste
- Conduct meetings with internal teams to initiate process streamlining projects
- Document, review, and update policy & procedures
- Train and coach new team members
- Create new training processes
- Respond to audit inquiries and draft corrective action plans
- Monitor corrective action plans
- Create deliverables trackers and monitor team production
- Notify Health Plans and process provider network changes
- Submit newly contracted & employed providers to contracted Health Plans for multiple entities
- Obtain, document, and maintain provider enrollment site IDs
- Support internal departments to resolve issues with Health Plans
- Communicate with Health Plans to establish new site codes and project plans
- Validate Health Plan network rosters on a quarterly and annual basis
- Continually research and identify significant membership movements and keep leadership current
- Conduct and lead monthly/quarterly meetings with Health Plans to address concerns and deliverables
- Create full network rosters for internal customers, marketing, and business development teams
- Disseminate new and revised policies internally and to contracted/employed providers
- Assist with evidence-based Health Plan audits
- Conduct internal administrative audits and maintain documentation for compliance purposes
- Provide monthly and quarterly reports to Health Plans
- Validate internal provider data for quality and accuracy to comply with Senate Bill 137
- Re-credentialing Applications for providers (PCP, Specialists, Mid-Levels)
- Create SOPs for initial and recredentialing of providers and HDOs for future training
- Conducted primary source verifications such as background checks and board certifications.
- Scan, organize and store provider files
Customer Service Representative/Utilization Management Coordinator
New Century Health Plan
2021.01 - 2021.07
- Responsible for processing medical requests all while providing great customer service
- Acted as the first point of contact for all Cardiology and Oncology claims to provide Authorization prior to reaching the Nurses
- Contacted physicians’ offices as well as Health Plans to complete treatment requests
- Escalated incoming calls, fax, and email inquiries regarding authorization status and eligibility
- Obtained authorizations from multiple insurance carriers for various levels of care.
- Submitted cases for criteria failures and helped facilitate resolutions and approvals.
- Actively listened to customers, handled concerns quickly and escalated major issues to supervisor.
- Clarified member issues and determined root cause of problems to resolve complaints.
- Participated in team meetings and training sessions to stay informed about member service updates and changes.
Coordinator/Compliance
Imperial Health Plan of California
2020.09 - 2020.12
- Compiled internal information for compliance audit by reviewing company policy documentation, non-compliance reports and investigations into questionable conduct.
- Educated employees by conducting compliance training programs and issuing periodic communications to refresh knowledge of compliant work practices.
- Implemented company compliance programs by researching changes in health plan legislation, maintaining company policy documentation and educating personnel on compliance policies.
- Promoted compliance by advising management on needed or prohibited actions to comport with government regulations.
- Developed and maintained compliance database, tracking all compliance activities and documents.
- Entered data, generated reports, and produced tracking documents.
- Gathered and organized materials to support operations.
- Created workflow to track member improvement assessments for Special Needs Program within Utilization Management Outpatient
- Place outbound calls to members to obtain High Risk Assessment Forms
- Created workflow to monitor and maintain High Risk Assessment Forms for Utilization Management
Coordinator
Blue Shield of California Promise
2016.07 - 2020.03
- Communicated with supervisors and colleagues to process data quickly and resolve discrepancies.
- Update and enter information to be within compliance timelines
- Communicate with Nursing Staff to assist with Care Plans
- Creating, reviewing, and submitting CMS documents
- Communication with other departments such as Enrollment, mail room, Member Services, and Administration
- Developed and updated spreadsheets and databases to track, analyze, and report on outcomes for Utilization Management for the Special Needs Program
- Accessed programs such as EZ Cap, EZ Care and RingCentral
- HIPAA, CMS, EUA and HPMS compliant
- Complete CMS reviews and verification checks with Member Services
- Create templates, guidelines, and teaching material for Appeals and Grievances
- Updating files for Organization Determinations Appeals and Grievances
- Utilization Management, Data Entry for Utilization Management
- Accurately input member and doctor information
- Correctly and time efficiently entered codes and information
- Approving authorizations
- Communication with providers to assist in adjusting per request
- Communication with other departments such as claims, Provider Relations and Enrollment
- Familiar with IPA authorizations and DOFRs
- HIPAA compliant
- Medicare, Medi-Cal and Cal-Medi-Connect capable
- Trainer for new hires for entire coordinator position
- Created training materials for coordinator role
Administrative Clerk
Halston Heritage
2015.10 - 2016.03
- Data Entry for Production
- Email correspondence as necessary
- Filing and scanning paperwork to ensure organization
- Developed and maintained efficient production processes and procedures.
- Completed logs and reports detailing production data such as volume, materials used and quality assurance results, helping management make accurate operational decisions.
- Collaborated with cross-functional teams to align production plans with customer requirements.
- Logging shipment information, ensuring that units are precise and correspond with shipping and warehouses data
- Prepared and documented shipment activities and cargo movements to enable tracking history and maintain accurate records.
- Monitored inbound and outbound freight operations to establish timely delivery of packages.
- Processed payments and documents such as invoices, journal vouchers, employee reimbursements, and statements.
- Inputting and identifying account chargebacks
- Reconciling retail transactions with vendors, banks and stores.
Education
Some College (No Degree) - Business Administration And Management
East Los Angeles College
Monterey Park, CASkills
- Microsoft Suite; Excel, Word, OneNote, Outlook and Power Point
- Adobe Creative Suite; PhotoShop, Bridge & Lightroom
- Auditing
- Utilization Management
- CPT Coding
- ICD-10
- Insurance Verification
- DMHC
- Business Relationship Cultivation
- Training Programs
- Operational Efficiency
- Internal & External Communications
Timeline
Health Plan Operations Specialist/Credentialing Coordinator
AltaMed/Altura MSO
2021.08 - Current
Customer Service Representative/Utilization Management Coordinator
New Century Health Plan
2021.01 - 2021.07
Coordinator/Compliance
Imperial Health Plan of California
2020.09 - 2020.12
Coordinator
Blue Shield of California Promise
2016.07 - 2020.03
Administrative Clerk
Halston Heritage
2015.10 - 2016.03
Some College (No Degree) - Business Administration And Management
East Los Angeles College
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