Vanessa Huanca
North Hollywood,CA
Summary
Bilingual healthcare professional with over five years of experience in the medical industry, specializing in appeals and grievances. Proven expertise in conflict resolution, quality analysis, and complex claims management. Recognized for exceptional problem-solving skills and a track record of exceeding performance goals. Aiming to leverage healthcare support expertise to improve operational efficiency and enhance member satisfaction.
Overview
6
6
years of professional experience
Work History
CSC Appeals & Grievances Specialist II
L.A. Care Health Plan
Los Angeles, California
12.2020 - Current
- Analyze and resolve verbal and written claims, authorization appeals, and formal grievances from members and providers.
- Prepare resolution letters and ensure that appropriate correspondence is used according to lines of business (LOB) and regulatory requirements.
- Handle escalated grievances from the Department of Managed Health Care (DMHC) with urgency and precision, ensuring timely resolution and adherence to regulations.
- Participate in quality initiatives and special projects to drive continuous improvement.
Appeal and Grievance Coordinator I
Centene/Insight Global
Woodland Hills, California
11.2019 - 05.2020
- Review and process member and provider grievances and appeals in accordance with federal, state, and organizational regulations.
- Evaluate claim grievances for reconsideration; approve, deny, or escalate for medical review as appropriate.
- Prepare and present complex cases for medical review, identifying potential issues related to quality or access.
- Collaborate with internal subject matter experts to obtain benefits and clinical interpretations needed for case resolution.
- Serve as a liaison between members, providers, regulatory agencies, and internal departments to ensure clear communication and timely resolution.
- Perform additional duties as assigned to support departmental and organizational goals.
Education
Bachelor of Science - Health Administration
Cal State University, Northridge
Northridge, CA06-2015
Associate of Arts - Business Administration
Santa Monica College
Santa Monica, CA06-2012
Skills
- Claims resolution and grievance processing
- Regulatory compliance
- Quality analysis and documentation standards
- Conflict resolution
- Time Management & Prioritization
- Customer Service Excellence
- Member & Provider Communication
- Root Cause Analysis
- Case Management Systems (CMS)
Languages
English
Full Professional
Spanish
Professional
Affiliations
- Passionate about health and wellness; regularly practice Pilates, Zumba, and strength training.
- Advocate for active living and mental well-being through movement and fitness.
References
References available upon request.
Timeline
CSC Appeals & Grievances Specialist II
L.A. Care Health Plan
12.2020 - Current
Appeal and Grievance Coordinator I
Centene/Insight Global
11.2019 - 05.2020
Bachelor of Science - Health Administration
Cal State University, Northridge
Associate of Arts - Business Administration
Santa Monica College
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