Wolf Moon
Orange,United States
Summary
Healthcare professional adept at managing grievances & appeals while adhering to stringent Federal and State guidelines. Excellent relationship-building, prioritization and time management skills. More than ten years pharmacy experience. Facilitates positive and productive interactions between workers, leaders and union representatives. Successful background reaching consensus and smoothing relations to maximize success of negotiations. Articulate and decisive professional with respectful and resourceful approach.
Overview
20
20
years of professional experience
Work History
Appeals & Grievances
CalOptima
02.2021 - Current
- Worked for CalOptima for over 3 years
- Helped peers and can proudly say I am a SME
- Crossed trained from Provider Relations, Intake, GARS Medi-Cal and Medicare OC grievances and appeals
- I have been provided experience through CalOptima processes to implement and teach best practices to ensure success of CalOptima Health.
- I am versed with programming and regulations required by CMS and DCHS strict guidelines to ensure department is within compliance.
Mobility Sales and Call Center
- Quality assurance
- Side by side training with peers and billing
- Soft call skills and broke the record for top customer service rep in 2016 in the USA.
Coordinator
Golden State Medicare Plan/ConnectedCare
03.2020 - 08.2020
- Considered a start up at the time, I had to build the universe and help aide the nurses with the proper clinical processes to submit the appeal to the Medical Director for review
- As the coordinator, it was my sole responsibility to work directly with the nurses, UM, and the Medical Director to ensure the appeals were completely per CMS guidelines and DHCS
- It was my responsibility to train and review the appeal process with the nurses and create an excel spreadsheet that contained the structure of the universe that would be implemented
- Analyze and resolve verbal and written Part C and Part D grievance/appeals from.
- Generate acknowledgement and resolution letters based on state and federal trun-around-times
- Review and process member and provider grievances and appeals within federal, state and organizational regulations and policies and procedures
- Review claim grievance for reconsideration and either approve/deny based on determination level or prepare for medical review presentation
- Prepare cases for medical review as necessary
- Review and determine if claim grievance includes a potential quality or access issue
Pharmacy Services Appeals & Grievances
UnitedHealth Group
12.2017 - 03.2020
- Appeals Coordinator is responsible for leading, organizing and supervising processes and daily workflow of prior authorization denial appeals including creation and maintenance of resources, workflows, staff training and coordination.
- Perform intake, processing and completion of pharmacy redeterminations (appeals).
- Take necessary steps to perform complete and accurate evaluation of non-formulary drug exception requests prior to approval, authorization or claim override.
- Plan, prioritize, organize and complete work to meet established and required regulatory timeframes.
- Contact prescribers to obtain additional clinical information or medical records when necessary
- Document all authorizations and denials completely and accurately, and in accordance with letters/timelines as defined by state and federal regulations to ensure appropriate notification to prescribing physician and impacted member
- Collect all pharmacy data/information and provide quality assurance review as required to support regulatory audits (e.g
- CDAG)
Supervisor, Pharmacy
Walmart
09.2010 - 06.2016
- Floor supervisor
- Trained new associates
- Accounting front end supervisor.
- Managed 4 departments
- Pharmacy
Pharmacy Clerk/Technician
Savon Albertson Pharmacy
06.2004 - 12.2008
Education
Bell Gardens High School
Bell Gardens, CAAssociate of Science - Education
Cal State Dominguez Hills
CarsonPharmacy Technology
Ashworth College
Norcross, GASkills
- Policy Knowledge
- Dispute Resolution
- Complaint Handling
- Training leadership
Secondary Phone
978-594-7554
Current Department
Grievance and Appeals
Current Supervisor
Luis Sierra
Current Position Title
GARS
Current Work Phone No
657-900-1119
Current Work Location
CalOptima
Primary Phone
978-594-7554
CEO of Moon Wolf LLC
Moon Wolf LLC is a business which I have started and ran since 2022.
As owner and CEO, I am in charge of delegating processes, creating a pitch deck and 3 year financial forecast to ensure the growth of my company. Any employees I hire, I train directly to ensure they follow the guidelines and processes of our business and uphold the integrity of our cause.
Timeline
Appeals & Grievances
CalOptima
02.2021 - Current
Coordinator
Golden State Medicare Plan/ConnectedCare
03.2020 - 08.2020
Pharmacy Services Appeals & Grievances
UnitedHealth Group
12.2017 - 03.2020
Supervisor, Pharmacy
Walmart
09.2010 - 06.2016
Pharmacy Clerk/Technician
Savon Albertson Pharmacy
06.2004 - 12.2008
Mobility Sales and Call Center
Bell Gardens High School
Associate of Science - Education
Cal State Dominguez Hills
Pharmacy Technology
Ashworth College
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