Toni Pedraza
Torrance,USA
Summary
Skilled specialist with proven track record in delivering impactful results. Adept at team collaboration and flexible in adapting to changing needs. Expertise in Appeals and Grievances, consistently driving successful outcomes. Known for reliability and strong focus on achieving objectives.
Overview
11
11
years of professional experience
1
1
Certification
Work History
Customer Solution Center Appeals and Grievances Specialist II
L.A. Care
12.2024 - Current
- Identifies, investigates, and resolves administrative complaints, complex provider appeals and State Fair Hearing adhering to CMS, DHCS, DMHC, MRMIB and NCQA standards and regulations
- Intakes, acknowledges, prepares case files and routes complaints to appropriate internal department for investigation and resolution, exercising strong independent judgment
- Ensures integrity of A&G database by thorough, timely and accurate assignment of cases
- Monitors closure of complaints and works with Quality Control Supervisor to resolve all database issues
- Prepare and analyze monthly appeal and grievance reports to meet internal and external reporting requirements
- Participates in internal and external oversight activities, inter-rater reliability reviews and focused audits
- Recommends opportunities for improvement
- Perform other duties as assigned
- Remote
Complaints, Grievances, and Appeals Liaison
Oscar
03.2020 - Current
- Handle a large volume of incoming grievances and appeals from receipt through resolution, ensuring that all appeals are resolved within contractual timeframes
- Insurance claims investigation
- Managing multiple cases to ensure each case has all of the required elements for processing and remains in compliance with state laws
- Perform complete, accurate and consistent documentation of all research, escalation pathways, and communications in Oscar systems, MS office software, (Excel, Word, PowerPoint), Google Docs, JIRA, Vam, Inovaare
- Write and manage outbound documents, correspondence and reports in required timeframes
- Identify operational issues and trends within Oscar, delegates and other external stakeholders
- Collaborate with key departments on all appeals and grievances
- Work collaboratively and cross functionally with other departments to facilitate appropriate resolutions
- Ability to function and excel in a remote environment handling time critical appeals and grievance cases
- Remote
Member Solutions Insurance Specialist
USAA
08.2017 - 02.2020
- Frontline underwriting
- Communicate with third party stakeholders
- P&C Licensed to facilitate product and Sales
Department Manager
Sprouts Farmers Market
07.2014 - 08.2017
- Purchase order/ invoice posting into accounting system(s)
- Reconciliation of vendor account invoices, statements, and company bank statements
- Data Entry - accounting systems/spreadsheets for profits and losses, training and development, inventory management
Education
Business Management with Human Resource Management Certificate-AAB -
10.2023
Bachelor of Science - Business Administration
Franklin University
Columbus, OH04-2026
Skills
- 4 years Experience with HIPAA and other federal and state laws and regulations applicable to the healthcare industry
- 4 years Experience utilizing Microsoft Office/Google Workspace applications
- 4 years Experience working in health insurance across several products specifically with claims processing, billing, reimbursement, or provider contracting
- Maintained complaint and grievance regulatory compliance to be 100% compliant with CMS requirements
- Analytical thinking
- Expert problem solving
- Documentation management
- Quality assurance
- Team collaboration
- Compliance monitoring
- Problem-solving
- Attention to detail
- Organizational skills
- Written communication
- Excellent communication
- Problem-solving abilities
Certification
Six Sigma White Belt Certification – July - 2017
Timeline
Customer Solution Center Appeals and Grievances Specialist II
L.A. Care
12.2024 - Current
Complaints, Grievances, and Appeals Liaison
Oscar
03.2020 - Current
Member Solutions Insurance Specialist
USAA
08.2017 - 02.2020
Department Manager
Sprouts Farmers Market
07.2014 - 08.2017
Business Management with Human Resource Management Certificate-AAB -
Bachelor of Science - Business Administration
Franklin University
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