Veronica Tavares
Boston,USA
Summary
To help build and strengthen the organization by cultivating its character through its vision and mission statement, fostering an inclusive environment through the diverse number of patients and help promote effective standards of care within its community.
Overview
10
10
years of professional experience
Work History
Appeals and Grievance Supervisor
Commonwealth Care Alliance
Boston, MA
01.2022 - Current
- Monitor and support the operations and compliance of the Appeals and Grievances department through many NCQA and other related quality program activities, including monthly case quality monitoring, coordination of training initiatives, coordination of Peer to Peer reviews with MDs, and preparation of case samples for audit review
- Work collaboratively with the AG Representatives and Management to support the development and maintenance of a quality program
- Report monthly quality results and identifying opportunities for improvement and training and areas on noncompliance
- Support compliance with CMS and MassHealth requirements and data checks for audit preparation and Policy and Procedure updates as required by regulations
- Partner with leadership on weekly strategy project calls while simultaneously moderating and overseeing internal department meetings and projects
- Provide updates and presents to leadership on current and future departmental process flows aimed at reducing inefficiencies and supporting operational processes
- Provide all department trainings on policies and procedures
- Build relationships with patients, providers, and vendor.
Program Advisor
Commonwealth Care Alliance
Boston, MA
07.2021 - 01.2022
- Conduct monthly case review of a random sample of appeals and grievance cases against previously developed scorecard and Federal and State Regulations. Complete individual summary scorecards for Supervisor feedback.
- Track monthly scores on spreadsheet and report monthly to management, highlighting training opportunities based on analysis of results
- Schedule Peer to Peer calls between requesting MDs and CCA MDs, per NCQA requirements.
- Coordinate BOH hearings with external State Hearing Board
- Help with preparation of NCQA audit review files (and other department audits as necessary) by using Adobe to combine and label system screen shots and case letters based on detailed audit regulations.
- Assist in the updating of department Policies & Procedures based on updates from State and Federal Regulators
- Run regular quality checks of CMS Universes to ensure team is inputting all required data points to ensure department is audit ready for yearly Timeliness Audit and for a full program audit
Appeals and Grievance Representative
Commonwealth Care Alliance
Boston, MA
07.2017 - 07.2021
- Responded to customer inquiries and complaints in a professional and timely manner
- Investigated and resolved customer appeals and grievances in accordance with applicable laws and regulations
- Provided daily supervision, including coordination of backup staffing, cross-training deployment, and including distribution of workload
- Hold staff accountable for regulatory and departmental standards and monitor daily production goals
- Identify root cause for any production issues, trends, root causes and mitigation
- Implement changes as necessary and monitor outcomes
- Report findings/solutions to Manager timely
- Performs recruiting, hiring, promotion, and performance evaluation tasks and counsels non-clinical A & G staff
- Orients and trains current and new A & G staff
- Provides approval decisions involving grievance billing/reimbursement determinations
- Collaborates with internal departments to ensure timely resolution
- Conduct routine 1:1s with direct reports
- Prepares and participates in Health Plan Audits, provides recommendations for Corrective Action Plans from state regulatory agencies
- Participate and/or lead organization quality improvement initiatives/projects
- Analyze operational and production reports on a daily, monthly, and quarterly basis
- Highly knowledgeable in relevant laws, regulations, and policies governing the appeals and grievance process
- Developed appeal and grievance processes and procedures organization
- Developed and implemented new grievance procedures, policies, and processes
- Trained and mentored staff to ensure compliance with Federal and State regulations.
Patient Access Supervisor
St. Elizabeth's Medical Center
Boston, MA
06.2014 - 06.2020
- Supervise day to day operations of Main Admitting, Pre-registration, and scheduling
- Organize, coordinate and delegate the daily activities performed by administration
- Work on claims to ensure they go out without any errors as well as monitor and create reports dealing with financial clearance
- Assist with both short and long term planning recommendations for all patient access staff
- Enforce department policies, practices and procedures in accordance with the hospital and union guidelines
- Provide daily support and training to all staff within the hospital
- Assist with new system updates and procedures by giving input and providing essential training guidelines for staff members
- Equip staff with supplies needed to ensure work flow
- Responsible for hiring new employees, giving disciplinary actions and performance assessments
- Prepare payroll and complete monthly schedules for Patient Access
- Work closely with the Director, CFO, Medical Records and Claims analyst to discuss trends and ensure quality, productivity and customer service
Education
Bachelors in Criminal Justice and Sociology -
University of Massachusetts, Boston
05.2014
Skills
- Strategic Planning
- Data Analytics
- Process Improvement
- Staff Management
- Complex Problem-Solving
- Staff Discipline
- Training and Mentoring
- Processes and Procedures
- Goal-Oriented
- Office Administration
Accomplishments
Cathedral High School 1000 point score
Girls AAU Basketball Coach- 2017-2020
Languages
Cape Verdean Creole
Native/ Bilingual
Timeline
Appeals and Grievance Supervisor
Commonwealth Care Alliance
01.2022 - Current
Program Advisor
Commonwealth Care Alliance
07.2021 - 01.2022
Appeals and Grievance Representative
Commonwealth Care Alliance
07.2017 - 07.2021
Patient Access Supervisor
St. Elizabeth's Medical Center
06.2014 - 06.2020
Bachelors in Criminal Justice and Sociology -
University of Massachusetts, Boston
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