Ambika Pradhan

*** ******* ******, #***

Hayward, CA 94542

510-***-****

abnwb5@r.postjobfree.com

Education

Masters in Science

California State University, Hayward, CA

M.S. in Health Care Administration

March 2004

Focus on management and change in healthcare.

Bachelor in Science

Lady Keane’s College, India

Major: Zoology

Minor: Biochemistry.

B.S. awarded June 1996

Ranked second in the top student merit list.

Training

Minority Training Program in Cancer Control Research

University of California, San Francisco (UCSF) 2004

Certificate of Achievement - Completed 12 hours continuing education units in Medicaid claims and

Medicare Billing and Reimbursement course 2005

Work Experience

Genentech Access Solutions-San Francisco, California.

Case Manager (Contractor)

July 2008 to current

*Provide customer-focused reimbursement support to patients, distributors, physicians and internal

sales force.

*Educate, inform, and assist patients and providers to navigate through reimbursement process.

*Identify barriers to reimbursement and continually identify and recommend ways to increase

efficiencies to promote high quality of work by SPOC/GATCF staff.

*Identify and facilitate referrals to alternative coverage options and financial assistance programs for

patients who are under-insured or require copy assistance.

HCR Manor Care Skilled Nursing Facility -Sunnyvale, California.

Unit Manager/ Social worker

June 2006 to July 2008.

*Provide overall administrative direction and coordination to run the unit effectively.

*Direct and coordinate with various departments such as nursing, housekeeping and activities to

ensure that the needs of the patient are met in a day to day basis.

*Deal sensitively with patients, their family and staff to ensure that urgent matters are drawn to the

attention of relevant staff quickly.

*Perform comprehensive social-psychological assessment according to the Manor Care policies.

Complete progress notes, updates and care plans in a timely manner.

*Coordinate medically related social services to assist residents in maintaining or improving their

ability to manage their everyday physical, mental and psychosocial needs.

*Provide linkage with community resources by maintaining knowledge of other systems, making

referrals and contacts, and identifying unmet needs of the patient.

*Monitor the effect of governmental and facility rules and regulations and their interpretation on the

everyday life of patient and their families.

*Involve residents and families in care planning, work with relevant staff to implement each

resident's care plan, addressing issues that express and reinforce individuality, identity and

independence.

*Involve and participate in weekly utilization review and case management for all Medicare and

managed care patients.

*Plan discharges with resident and family participation to assure continuity of care for transfers and

discharges from the facility.

*Participate in review for appropriateness of admission applications and provide referral as needed.

*Adhere to all policies and procedures of the center and perform other tasks as assigned by the

administrator.

*Assure enhanced customer service through timely follow-up to patient and family concerns.

*Work on patient’s behalf to identify and assess reimbursement coverage options for those with

insurance and to coordinate and/or investigate financial options for those without long term care

insurance.

*Consistently exhibits behavior and communication skills that demonstrate commitment to superior

customer service, including quality, care and concern with each and every internal and external

customer.

United Behavioral Health (UBH)-San Francisco, California

Senior Administrative Appeals Review Specialist

February 2005 – June 2006

*Responsible for review, evaluation, research, and resolution of mental health/substance abuse

appeals in compliance with account, state, federal, and accreditation requirement.

*Address reimbursement-related inquiries, assess patient’s coverage options, and conduct insurance

benefit verification.

*Investigate relevant information by conducting a thorough review of behavioral health benefits,

eligibility, clinical case notes, and care management procedures and/or claims payments.

*Analyze and evaluate information to make a determination regarding the resolution of appeal

request.

*Interface with multiple departments, both internal and external to UBH, to resolve complex issues.

*Communicate in writing or verbally to appropriate parties / members regarding the appeal

outcome.

*Document reports and keep up-to-date records of all mental health/substance abuse appeal

activities

*Assist Supervisor in operational management of Appeals Unit, training and mentoring to new staff.

*Provide input in the development and enhancement of business processes within the unit and

between other departments. Provide coverage during staff absences or during times of low staffing

*Maintain privacy and confidentiality of information, protect the assets of the organization, act with

ethics and integrity, report non-compliance, and adhere to applicable regulations.

*Consistently provide a high level of customer service. Assist with day-to-day patient reimbursement

cases

Kaiser Permanente National Diversity Dept-Oakland, California

National Linguistic & Cultural Programs, (NLCP)

Research Assistant-Intern

June 2003 – July 2004

*Research and design culturally appropriate tools to collect quality data on patient satisfaction

*Attend and document the Healthcare Interpreter-Training Course to obtain student’s relevant

response about the course and the teaching materials on a daily basis.

*Evaluate the Healthcare Interpreter-Training Program and prepare a report that reflects what areas

in the courses/ teaching materials needs to be modified.

*Participate in the development of the Language Lab Coach Manual for the Healthcare Interpreter-

Training Program

*Provide and assist with advice/consultation to department and present current research findings

about the project on a weekly basis.

*Document and maintain research findings into department’s library database for future reference.

Sarvanga Nursing Home & Research Center-Kathmandu, Nepal.

Patient Service Coordinator

August 1996-September 1998

*Maintain personal files and records of patients, schedule patients for appointments, tests, and x-

rays, relay information to patients regarding preparation for laboratory tests and examinations.

*Ensure patient case notes are kept up to date and in good order.

*Deal sensitively with patients, and clinical staff and ensure that urgent matters are drawn to the

attention of relevant staff quickly.

*Participate in interdisciplinary team discussions to ensure that care and services provided are

appropriate for patient needs.

Skills

* Self-Motivated, strong interpersonal skills, quick learner, team player, detail-

oriented, hard working.

* Leadership: Founder & Vice-President for the Healthcare Administration

Association (MHCA) at California State University, Hayward, 2002-2003

* Extensive knowledge in different types of health insurance – public and private payers

*Computer Skills: MS Word, Excel, Access, MS Project, Visio.

*Languages: Fluent in English, Hindi, Nepali. Beginning American Sign Language.

References

Provided on request

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