Vianey Vanlizzen
Eastvale,CA
Summary
Dedicated to maintaining customer satisfaction and contributing to company success. Reliable and driven, with strong time management and prioritization abilities.
Overview
8
8
years of professional experience
Work History
Plan Administrator
Public Agency Retirement Services
01.2022 - 01.2025
- Serve as the main point of contact for clients, plan administrators, and Spanish speakers. Managing complex inquiries regarding various retirement plans.
- Manage high-volume client interactions, including calls and paperwork processing, ensuring accuracy and timely resolution of participant requests while also facilitating efficient communication between departments, partners and financial institutions to update account details and process changes.
- Lead presentations and client meetings, leveraging strong public speaking and critical thinking skills to navigate and resolve complex issues.
Appeals and Grievances Analyst
Golden State Medicare Health Plan
01.2020 - 01.2022
- Responsible to review, analyze and process pre-service and post service grievances and appeals requests related to clinical and non-clinical services.
- Utilized guidelines and review tools to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize and route to nursing and/or medical staff for review.
- Investigate and resolve member and provider appeals and grievances.
- Identify, analyze and research pre and post-service denials for members and providers.
- Process all appeals and grievances within regulatory guidelines.
- Respond in writing to members and providers.
- Make informed judgements on the proper application of members’ health plan benefits, accurate adjudication of claims & referrals, etc.
- Maintain Appeals & Grievances logs and data bases timely and accurately
- Serve as a liaison between grievances & appeals and /or medical management, legal, and/or service operations and other internal departments.
- Create case files for all appeal upholds, and submit to our independent review entities portal, Maximus Federal Services.
Member Advocate
Golden State Medicare Health Plan
01.2019 - 01.2020
- Accurately respond to inbound phone calls
- Provide Doctors and members with routine health care investigate and resolve member and provider appeals and grievances.
- Information on effective dates of coverage, claims history
- Deductible and coinsurance amounts, and medical benefits.
- Escalate calls and file grievances when necessary
- Follow established policies and procedures
- Arrange transportation for members, monitor transportation count and report issues encountered
- Assist with Eye wear and Hearing aid reimbursements, identify if additional information is needed or if it has to be forwarded to the correct payer
- Follow CMS guidelines
Marketplace Escalations, Sr. Representative
Molina Healthcare
01.2018 - 01.2019
- Responsibilities begin with a review of escalations received via internal operating system (CRM) to determine if the issue needs to be worked, redirected or educating agents through coaching package that is sent to their supervisor via SharePoint, as well as tracking root causes of escalations to identify potential trends to develop and implement solutions.
- Became a dedicated enforcer of health insurance portability and accountability act (HIPAA) by complying with all rules and regulations.
- Collaborate with various departments like the bridge line, HICS cases, escalated claims, appeals and grievances, enrollment and accounting.
- Assisted leadership staff with Special Projects
- Social Media Cases
Member service Representative 1
Molina Healthcare
01.2017 - 01.2018
- Accurately respond to inbound phone calls
- Provide facilities, doctors and members with routine health care Information on effective dates of coverage, claims history, Deductible and coinsurance amounts, and medical benefits.
- Escalate calls and file grievances when necessary
- Follow established policies and procedures
- Premium payments
- Assisted leadership staff with Special Projects
Education
High school diploma - undefined
Parkridge private school
01.2005
Skills
- Typing 40 WMP
- Problem Solving
- Team Leadership
- Microsoft Office
- Fluent Spanish Speaker
- Effective time management
- Conflict Resolution
- Project Management
- Adaptability
- Self Motivated
Timeline
Plan Administrator
Public Agency Retirement Services
01.2022 - 01.2025
Appeals and Grievances Analyst
Golden State Medicare Health Plan
01.2020 - 01.2022
Member Advocate
Golden State Medicare Health Plan
01.2019 - 01.2020
Marketplace Escalations, Sr. Representative
Molina Healthcare
01.2018 - 01.2019
Member service Representative 1
Molina Healthcare
01.2017 - 01.2018
High school diploma - undefined
Parkridge private school