Vivian Gregorio
UnitedHealthcare
Lakewood,CA
1
Certificate
14
Years of experience
Results-driven Claims Business Process Analyst with a focus on process improvement, data analysis, and team collaboration. Achieved significant operational efficiencies through strategic enhancements and automation.
Work History
Claims Business Process Analyst
3 Years 7 Months- Analyzed business processes to identify inefficiencies and recommend improvements On the Standard Operating Procedure And Training Development for existing and new employee.
- Collaborated with cross-functional teams to gather requirements for system enhancements.
- Developed process documentation, ensuring accuracy and compliance with industry standards.
- Conducted data analysis to support decision-making and optimize operational workflows.
- Facilitated training sessions on new tools and processes for team members.
- Implemented change management strategies to ensure smooth transitions during process modifications.
- Evaluated existing systems to identify opportunities for automation and increased productivity.
- Streamlined business processes by analyzing and identifying areas for improvement, reducing inefficiencies and boosting productivity.
- Established strong relationships with internal clients to better understand their needs and expectations related to process improvements.
- Collaborated with upper management to drive strategy and implement new processes.
- Implemented new process automation tools to enhance overall workflow and increase operational efficiency. This includes testing the automation tools, provide feedback and provide training and support to the end user.
- Performed root-cause analysis on recurring issues within existing processes, identifying solutions that addressed underlying causes effectively.
- Collaborated with cross-functional teams to develop optimized business processes, resulting in improved collaboration and communication.
- Provided ongoing support to team members during transition periods following process updates, minimizing disruption and maintaining productivity levels.
- Served as a subject matter expert on business process analysis methodologies within the organization, mentoring junior team members as needed.
- Led workshops for stakeholders to gather feedback on proposed process changes, fostering a collaborative approach to optimization efforts.
- Facilitated training sessions for employees on newly implemented processes, ensuring seamless adoption across the organization.
- Mapped processes to holistically examine business flow and identify improvement opportunities.
- Coordinated testing efforts for proposed changes to ensure smooth integration into existing systems without compromising functionality or stability.
- Developed comprehensive documentation of current processes, enabling easier analysis for future enhancements.
- Presented findings from process analyses to senior management, securing buy-in for recommended improvements and facilitating implementation efforts.
- Actively participated in continuous improvement initiatives, fostering a culture of innovation and growth within the organization.
- Built strong relationships with customers through positive attitude and attentive response.
- Mentored and guided employees to foster proper completion of assigned duties.
- Facilitated training for associates through daily coaching and regular performance appraisals.
- Demonstrated knowledge of company mission and goals and mentored employees in reaching objectives aligned with company core values.
- Partnered with supervisor, Subject Matter Experts (SME) and Managers in addressing quality issues within the team. Provide subjective feedback to improve quality of work to avoid defects.
- Assisted with new hire processing and existing training programs.
- Initiated timely response to emails, voicemails, and written correspondence.
- Analyzed data to identify root causes of problems and recommend corrective actions.
- Identified patterns and trends in large data sets and provided actionable insights.
- Provided technical support for troubleshooting analytics and reporting issues.
Claims Business Process Analyst (SME)
1 Year 1 Month- Analyzed business processes to identify inefficiencies and recommend improvements.
- Collaborated with cross-functional teams to gather requirements for process enhancement initiatives.
- Developed process documentation and workflow diagrams to support operational efficiency.
- Conducted data analysis to track performance metrics and identify areas for improvement.
- Assisted in implementing new technologies to streamline operations and improve service delivery.
- Ensured compliance with industry standards by reviewing and updating process documentation regularly.
- Supported training sessions for team members on newly implemented processes and tools.
- Works as a Triage Analyst and Resolution Analyst on Member Appeals and Grievances for MI & WI Medicaid Members
- Acts as a Hearing Facilitator for MI Member Appeals CommiCommittee Hearing & WI Panel Hearing for Medicaid Members Appeals.
- Provides support to all MI & WI Medicaid Resolution Analysts which includes in depth research of the Standard Operating Procedure and State Compliance and Regulations.
- Coordinated weekly meetings for internal and external groups.
- Review all reports including open inventory, executive summary and commentary report, pharmacy error report, acknowledgement letter report and resolution letter report.
- Developed training materials to enhance team knowledge on regulatory compliance and best practices. This includes updating the SOP when the contract with the State Medicaid is updated or renewed.
- Reviews, analyze and responds to any quality defects committed by all the team members.
- Managing the inventory making sure all cases are in compliance. This includes managing the hearing schedules for both MI & WI.
Resolution Analyst
1 Year 1 Month- Analyzed complex claims to identify root causes of issues and recommend resolutions.
- Collaborated with cross-functional teams to streamline operational processes and enhance service delivery.
- Serves as a Triage Analyst and Resolution Analyst for Member Appeals and Grievances specializing in WA and TX Medicaid Members.
- Resolve cases and implementing quality assurance measures to ensure compliance with regulatory requirements and company standards.
- Conduct through investigation, gathering all relevant information and documentation to make informed decision on each cases.
- Collaborate with business partners and health plan in resolving the member's complaints.
- Facilitated resolution of escalated member inquiries, enhancing customer satisfaction through effective communication.
- Leveraged strong analytical skills to identify patterns in customer complaints and propose data-driven resolutions.
- Enhanced customer satisfaction by promptly resolving complex issues and providing effective solutions.
- Demonstrated expert knowledge of industry regulations, compliance requirements, and internal policies when addressing client concerns or disputes.
- Maintained comprehensive documentation of all cases handled, ensuring accuracy and accessibility of information for future reference.
- Conducted root cause analyses to identify underlying issues and provide actionable recommendations for resolution.
- Established a positive rapport with clients by maintaining open lines of communication throughout the resolution process.
- Managed a high volume of cases simultaneously while maintaining exceptional attention to detail and adherence to established timelines for resolution.
- Stay updated with relevant regulation, policies, compliance and health plan's best practices related to member appeals and grievances, incorporating these knowledge into daily work activities.
Sr. Appeals Coordinator
7 Years 6 Months- Led multidisciplinary teams to resolve complex appeal cases efficiently.
- Developed and implemented streamlined processes for appeals workflow management.
- Mentored junior coordinators, enhancing team performance and knowledge sharing.
- Analyzed appeal trends to identify areas for improvement in compliance and quality assurance.
- Review, analyze and resolve Members and Non-par Provider Appeals For Medicare Part C Members.
- Verify member's eligibility with UHC to ensure accurate processing of the appeals.
- Review related claims in the NICE System.
- Assess financial risks based on the member's plan.
- Collaborate with Medical Groups as well as different business partners to ensure a quality review of the case.
- Conduct in depth review of each cases ensuring that all policies and compliance are met.
- ensuring that all closing letters are sent and cases are closed timely.
- Utilized electronic health record systems to maintain accurate documentation of appeals processes.
- Ensured regulatory compliance by staying current with industry updates and adjustments to relevant laws and policies.
- Maintained detailed records of all case files, ensuring easy access to necessary information for review or future reference.
- Enhanced team performance by providing ongoing training, support, and feedback for junior Appeals Coordinators.
- Mentored new hires, sharing expertise and insights gained from years of experience as a Senior Appeals Coordinator, contributing to overall team success.
- Provided exceptional customer service by addressing concerns empathetically while remaining focused on achieving positive outcomes for the company.
- Increased client satisfaction by providing thorough and timely responses to inquiries regarding appeal status and outcomes.
Appeals Coordinator
4 Months- Coordinated appeals process, ensuring compliance with regulatory standards and internal policies.
- Reviewed and analyzed appeal cases to determine appropriate resolutions and recommend improvements.
- Developed training materials for staff on appeals procedures and best practices for case management.
- Facilitated communication between members, providers, and internal departments to resolve disputes effectively.
- Implemented workflow enhancements that improved efficiency in the appeals processing system.
- Mentored junior team members on complex cases, fostering skill development and knowledge sharing.
- Led initiatives to streamline documentation processes, reducing turnaround time for appeal decisions.
- Conducted audits of appeal outcomes to identify trends and inform strategic decision-making processes.
- Acted as a departmental resource on appeals matters.
- Created, composed and maintained appeal response templates.
- Monitored changes in regulations or policies, updating internal procedures accordingly to maintain compliance.
- Organized and managed appeals caseloads, prioritizing high-priority cases for timely resolution.
- Developed strong working relationships with internal and external stakeholders, fostering a collaborative environment for efficient resolution of appeals.
- Coordinated with medical professionals and subject matter experts for case reviews, obtaining necessary clarification for accurate decisionmaking.
- Provided support during peak periods by assisting other departments with workload overflow; demonstrating adaptability.
- Participated in regular meetings with management to provide updates on case status and discuss potential improvements in processes.
- Provided exceptional customer service by promptly responding to inquiries from appellants and other stakeholders.
- Maintained strong knowledge of basic medical terminology to better understand services and procedures.
- Generated, posted and attached information to claim files.
- Reviewed outstanding requests and redirected workloads to complete projects on time.
Education
Associate of Applied Science - Healthcare Administration
Bachelor of Science - Medical Technology
Skills
Technical team interactions
Team collaboration
Effective communication
Process change management
Data monitoring
Knowledgeable in MS Word
Excel
Power Point
Teams
OneNote
Power BI.
Presentation skills
Procedure updating
Meeting participation
Data assessment and analysis
Quality reporting
Data-driven decision making
Process improvement expertise
Teamwork
Cross-functional team leadership
Teamwork and collaboration
Problem-solving
Time management
Problem-solving abilities
Attention to detail
Reliability
Team leadership
Active listening
Critical thinking
Customer service
Certification
Project Management
Languages
English
Professional Working
Timeline
Claims Business Process Analyst
UnitedHealthcare
11.2022 - 06.2026Read More
Claims Business Process Analyst (SME)
UnitedHealthcare
10.2021 - 11.2022Read More
Resolution Analyst
UnitedHealthcare
09.2020 - 10.2021Read More
Sr. Appeals Coordinator
UnitedHealthcare
03.2013 - 09.2020Read More
Appeals Coordinator
UnitedHealthcare
11.2012 - 03.2013Read More
Santa Barbara City College
Associate of Applied Science from Healthcare Administration
Read More
Far Eastern University
Bachelor of Science from Medical Technology
Read More