Yvonne Valencia
Downey,California
Summary
Experienced Supervisor successful at motivating and building positive team dynamics to accomplish company's goals. Practical problem-solver with excellent issue and conflict resolution skills to drive team and organizational success. Highly effective and knowledgeable in process improvement, best practice strategies and inventory control.
Overview
12
12
years of professional experience
Work History
Supervisor, Health Claims
SCAN Health Plan
05.2017 - 03.2023
- Coordinate day-to-day claims operations tasks in accordance with established policies and procedures, standard operating procedures, and job aids to ensure optimal performance results.
- Monitor and track claim inventory / workflow through entire claim life cycle to ensure timely processing of claims based on regulatory and contractual compliance requirements.
- Responsible for driving team results based upon established departmental quality and production performance metrics. Monitored team performance, including monthly 1:1's
- Assist Claims Management in identifying, creating, and implementing policies and procedures, standard operating procedures, and desk top references.
- Championed claims process by providing expert knowledge and building positive, trusting relationship to support team during challenging times.
- Build strong, professional functional teams through training reinforcement, coaching, motivation, and performance management.
- Complete and track effective performance evaluations and maintain ongoing dialogue with team members regarding development opportunities. Take part in all employee performance reviews and assisted hiring appropriate candidates.
- Utilized available incentive programs to reward, recognize and celebrate team and individual success.
Claims Supervisor
Molina Healthcare, Inc
01.2015 - 04.2017
- Acted as liaison with both Washington Provider Relations and South Carolina Provider Relations teams to investigate and resolve claims payment and configuration issues;
- Lead team to mitigate claims inventory, including high dollar inpatient and professional claims;
- Ensured team’s quality performance was at exceptional levels;
- Created and rolled out claims training materials for both Washington and South Carolina;
- Interacted with other Claims site (Detroit) to improve overall claims production efficiency and quality and mitigate Health Plan concerns.
Team Lead
Molina Healthcare, Inc
01.2014 - 01.2015
- Worked with South Carolina and Washington front line teams in helping them achieve production and quality goals;
- Mitigated conflicts involving claims guidelines, including clarifying and documenting correct claims processes;
- Actively participated with Puerto Rico interview event to help open Molina’s sister claim processing site;
- Worked with Detroit operation team to ensure clear communication channels between the two sites;
- Assisted with training of new hires;
- Actively participated with Saturday overtime to reduce long standing inventory challenges.
Vendor Analyst
Molina Healthcare, Inc
01.2012 - 01.2014
- Responsible for overseeing vendor staff to ensure adhering to regulatory and compliance requirements in addition to Service Level Agreement (SLA);
- Facilitate weekly/monthly vendor meetings to address quality, staff performance, and address specific trends with internal and external management;
- Organized training events between Molina and claims vendor to improve onboarding of new associates, improve claims quality, and improve production turnaround times;
- Maintain quality scorecard, reconciliation reports and oversee Quarterly Business Reviews
- Assisted in implementing new market, South Carolina to claims vendor in order to meet regulatory production and quality standards.
Claims Examiner I
Molina Healthcare, Inc
01.2011 - 01.2012
- Exceeded departmental production and quality standards including Financial Incident Accuracy and Financial Dollar Accuracy Standards;
- Became subject expert matter related to Texas Medicaid UB and CMS 1500 claim types;
- Executed and resolved highly complex claims, including those over $250,000;
- Resolved misrouted challenging claims;
- Developed strong working relationships with other Molina Departments, and outside vendors to escalate, mitigate, and remedy claims issues, disputes, and learning gaps;
- Worked various claims reports such as Post Timely Report, Temp Provider, and Auto Loader to ensure that claims production and quality standards were met.
Skills
- Application literate in IKA Claims System, QNXT, WebStrat, and EncoderProcom;
- Working knowledge of MS Office Products;
- Problem-solving, process improvement, multitasking, coordinating, and planning/implementing;
- Knowledge in medical terminology: ICD-10, CPT, HCPCS, and Hospital Revenue Codes;
- Training and mentoring
- Staff Management
- Employee Motivation
- Staff Development
- Operations Management
- Strong interpersonal communication skills;
- Goal-Oriented
- Bilingual
Claims Team Achievement 4.5 Star Rating 2018-2023
- Educating the team on how each area of business impacts customer service; informing the team we all play a pivotal role in the members experience
- Focusing on key areas that have high impact on score; addressing and tracking appeals and complaints appropriately and in a timely manner
- Track and monitor audit errors to identify issues and deficiencies
- Shared audit error feedback and provided training to the team
- Implemented technology and/or process improvements and update documentation to streamline a processes
- Continuous monitoring of timeliness with front end claims; being compliant with CMS
Timeline
Supervisor, Health Claims
SCAN Health Plan
05.2017 - 03.2023
Claims Supervisor
Molina Healthcare, Inc
01.2015 - 04.2017
Team Lead
Molina Healthcare, Inc
01.2014 - 01.2015
Vendor Analyst
Molina Healthcare, Inc
01.2012 - 01.2014
Claims Examiner I
Molina Healthcare, Inc
01.2011 - 01.2012
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