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CHERI K IYOKO K IM C MA,XT W est C ovina, C A * **92 • ( 626-*-**-**** •

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Education

Kaplan C ollege

Medical A ssistant/ X -ray T echnician P rogram Experience

St. J ude M edical C enter A ugust 2 017 - p resent Authorization S pecialist

● Responsible f or s ubmission o f C hemotherapy t reatment a nd R adiologic s ervice r equests t o contracted n etwork H ealth P lans

● Works c losely u nder t he d irection o f t he O ncology M edical P hysicians a nd/or t he D irector o f Nursing S ervices.

● Coordinate w ith p roviders, s taff a nd p atients t o e nsure c linician r eferrals a re c ompleted a nd processed i n a t imely m anner b ased o n c linically a ccepted g uidelines.

● Responsible f or r eviewing g uidelines f or r eferrals, c ontacting a ppropriate p roviders, p atients, s taff and o utside a gencies a s n eeded, a nd t racking t hese r esults o n a n i ndividual a nd g roup b asis t hrough the r eferral

● Ensuring i nternal a nd e xternal c lients a re p rovided w ith e xceptional c ustomer s ervice.

● Determining a nd v erifying p atient p rogram/insurance e ligibility r equirements, p roviding p atient appointment s cheduling, h andling s canning/inputting r equired p atient i nformation, p roviding referrals a nd p rogram s ervices, a nd o ther d uties a s a ssigned.

● Highly e ffective w ritten & v erbal c ommunication s kills

● Utilizes e xcellent t elephone e tiquette a nd c ustomer s ervice s kills, i ncluding t he a bility t o c onverse politely a nd e ffectively w ith t roubled i ndividuals

● Maintains h igh l evel o f k nowledge o f i nsurance c overage a nd a uthorization r equirements

● Required t o t hink i ndependently a nd u se g ood j udgment f or s ituations w hich r equire i nitiative a nd innovation

● Expert c omputer s kills i n r egistration, s cheduling s ystems

● Knowledge o f c omputer s oftware p rograms a nd u se o f b asic o ffice e quipment

● Required t o m ulti-task a nd p rioritize n eeds t o m eet r equired t imelines

● Expected t o h ave e xcellent a nalytical a nd p roblem-solving s kills

● Verify b enefits b y c alling i nsurance c ompanies a nd s peaking t o a c ustomer s ervice r epresentative.

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● Determining i f a uthorization i s n eeded.

● Responsible f or p reparing n ecessary p aperwork t o b e p ut t ogether s ending i nto t he p recertification department t o o btain t he n ecessary a uthorization.

● Documenting i n d etail n otes i nto a llscripts a nd I DX s ystems a s t o w hat e xactly t he p atient i s covered f or a nd n ame o f t he a uthorization s pecialist f rom t he i nsurance c ompany, a uthorizing t he benefits.

Linking t he n otes t o t he a ppointment, f amily i nsurance a nd p rimary p hysician w ith o ut p atient services

● Filling o ut c ustom s creens a nd p utting i n p rintable c omments s o t hat t he r egistrar w ill k now w hat i s to b e c ollected, s uch a s c o p ay, r eferral.

● Notifying f amily o f s ervices t hat a re n ot c overed a nd s etting u p f inancial a rrangements f or p ayment at t ime o f s ervice.

● Advising f amily o f o ur f inancial a ssistance p rogram a nd s ending o ut t he n ecessary f orms t o b e completed a nd r eturned b efore s cheduled a ppointment t o s ee i f t hey f amily q ualifies f or f inancial assistance.

● Responsible f or m anaging f inancial p ayment, i nsurance a uthorization a nd d ocumentation, a nd durable m edical e quipment p urchases.

● Duties a re c ritical f or i nitial a nd u ninterrupted o ngoing o utpatient c are a nd t o t he f acilities' economic p erformance.

Central H ealth M edicare P lan J une 2 015- J une 2 017 Utilization M anagement S upervisor

● Promoted w ithin 7 m onths f rom U tilization M anagement C oordinator S pecialist t o U tilization Management S upervisor

● Coordinates a nd p articipates i n t he r eview p rocess a nd a udit p rocess w ith e ach I PA/Medical G roup

● Update a nd m aintain U M p olicies a nd p rocedures t o r eflect C MS c hanges

● Participates i n J oint O perational C ommittees ( JOM)

● Coordinates a nd l eads t he U tilization M anagement C ommittee M eetings q uarterly, o r a s n eeded

● Requested t o a ct a s A ppeals a nd G rievance S upervisor a s o f 0 5/2016 d ue t o r estructing t he e ntire department

● Works c losely w ith t he C hief M edical D irector o f t he H ealth P lan t o r eport a ny p ertinent information r egarding u pdated i nformation p ertaining t o t he U tilization M anagement D epartment.

● Works c losely w ith o n-site M edical D irector o f U M/QM a nd p resenter o f Q M c ommittee m eetings

● Responsible f or r eporting a nd c reating s tatistic c harts f or a ppeals a nd g rievance q uarterly m eetings.

● Responsible f or s ubmission o f Q uarterly D ata V alidation R eports a nd C MS U niverse R eports f or program a udit

● Maintains a ccurate f iles a nd i nternal a udit r eports f or e ntire u tilization m anagement s taff f or referral a uthorizations a nd r eviews

● Develops c orrective a ction p lans a nd f ollow u ps a s n ecessary f or o ut o f c ompliance r elated i ssues 2 o f 4

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● Develops n ecessary t ools a nd/or p rocedural f orms a s n ecessary

● Supervises t he c ompliance-mandated c riteria u sed i n M anaged C are

● Maintains a p rofessional r elationship w ith p roviders, s pecialists a nd h ealth p lan p ersonnel

● Assures d epartmental c ompliance w ith h ealth p lan’s p olicy a nd p rocedures

● Recruit, s elect; t rain; d iscipline; d ischarge a nd d evelop s taff c ompetency

● Develop g oals a nd o bjectives f or b oth t he d epartment a nd i ndividual e mployee. D evise m ethods f or employees i ndividually a nd a s a d epartment, t o o btain g oals. F acilitates e ffective c ommunication with d epartment s taff r elative t o C entral H ealth M edicare P lan

● Conducts s taff m eetings, a ssuring p olicy a nd p rocedures a re a dhered t o a nd w hen n ecessary, modified t o a ddress c hanging s trategic o bjectives

● Identifies p roblems w ithin t he d epartment, a nalyzes a nd r esolves w ith a ppropriate a ction

● Worked c ooperatively w ith o utside c onsulting g roup, C ompliance S trategies, I nc i n r estructuring the A ppeals a nd G rievance d epartment.

Central H ealth M edicare P lan N ov. 2 014 - J une 2 015 Utilization M anagement C oordinator S pecialist

● Promoted w ithin 2 m onths f rom Q M/Appeals a nd G rievance C oordinator t o U tilization Management C oordinator S pecialist

● With m inimal s upervision, c oordinates a nd p articipates i n t he r eview p rocess o f r equested authorizations

● Responsible f or c hecking t he r eferral f orms f or c ompleteness, o btaining m issing d emographic information a s n eeded, a nd i nitial a ttempts a t c oding a nd u ncoded r eferrals

● Responsible f or m eeting a ccuracy s tandards f or a ppropriate a uthorizations o f r eferrals

● Communicate w ith p roviders i n c onsultation w ith t he U tilization M anagement M edical D irector and o r U tilization M anagement N urses, r egarding a uthorizations; m odifications; d enials a nd o ther matters p ertinent t o p rocessing a uthorization r equests a nd o r o ther U tilization r elated correspondence

● Assist m anagement o r M edical D irector a s n eeded

● Maintain P &Ps b y u pdating n ew p olicies a nd p rocedures a pproved b y t he U tilization M anagement Committee B oard

● Responsible f or p ulling i nternal r eports f or U M C oordinators i nternal a udits i n o rder t o c heck accuracy a nd t imeliness o f r eferrals t o e nsure q uality a nd c ompliance p er C MS r equirements f or organization d eterminations

● Responsible f or R etro I PA C laims, R etro C linical R eview a nd O rganization D eterminations t hat are f orwarded f rom t he A &G d epartment; p re-service O Ds; p ost-service O D a nd D MRs

● Responsible f or p ulling r eports f or D ata V alidation a nd a ccurately c leaning o f t he e ntire U tilization department’s d ata

Central H ealth M edicare P lan S ept. 2 014- N ov. 2 014 QM/Appeals a nd G rievance C oordinator

● Be t horoughly f amiliar w ith r egulatory g uidelines a nd s tandards w hich p ertain t o t he p osition, i e., NCQA, C MS, D MHC, C a H ealth & S afety, B usiness a nd P rofessional C odes a nd C alifornia Federal C ode o f R egulations

● With m inimal s upervision, c oordinate p rojects a nd a ssist w ith c lerical a nd a dministrative s eries a s 3 o f 4

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assigned b y t he D irector o f Q uality M anagement

● Maintain c onfidentiality a t a ll t imes

● Assists w ith H EDIS o bjectives a s e stablished b y t he D irector o f Q uality M anagement

● Assist i n o btaining r ecords a nd c ontacting p rovider o ffices f or A ppeals a nd G rievances

● Interfaces w ith p hysicians, v endors, m embers a nd o ther i nternal d epartment s taff t elephonically o r by e mail

● Coordinates m eetings, t rainings a nd p resentations

● Produce/provide v arious r eports a s r equested f or i nternal c ustomers s uch a s, b ut n ot l imited t o, UM, N etwork M anagement, A ppeals a nd G rievances

● Filing, f axing, c opying a nd p urging f iles

● Maintains s trict t urnaround t imes f or v arious Q I r elated a ctivities/reports

● Assists i n h ealth p lan a udits a nd a ny c orrective a ctions, a s n ecessary

● Prepare a nd c onduct q uarterly Q uality M anagement m eetings a nd m aintain m inutes

● Generate a nd p rovide a ppropriated r eports a nd d ocumentation t o t he Q uality M anagement Committee m eetings

● Develop a w orking r elationship w ith e ach o f t he c ontracted C PG/IPAs i n o rder t o f acilitate a nd exchange i nformation

● Maintain a ppropriate d atabases f or Q uality M anagement a ctivities, s uch a s A nnual A ccess S tudy, Member S atisfaction S urveys, a nd D isease M anagement S tudies

● Responsible f or t he d ay-to-day a ctivities a nd c ommittee m eeting p reparation f or A ppeals a nd Grievances t o i nclude s tatistical r eporting, t racking a nd t rending o f c ases.

● Perform c linical c ase r eview f or a ppeals, g rievances a nd q uality o f c are i ssues Smart C linic

X-ray T ech/Medical A ssistant J an. 2 012 - M ar. 2012

● Gathered i ntake o f p atients’ h istories, i nput t hem i nto e lectronic m edical r ecords s ystem, a nd explained m edical p rocedures t o p atients

● Prepared a nd a ided p atients f or e xaminations, t reatments a nd o ther m edical p rocedures

● Administered i njections, v accines, a nd m edications

● Collected b lood s amples f rom p atients f or f urther l aboratory t esting

● Administered m edications v ia i nhalations f or p atients s uffering b reathing d ifficulties

● Physically e xamined p atients f or o ccupational m edicine

● Answered p hones a nd s cheduled a ppointments f or f uture v isits

● Prepared p atients f or r adiology e xaminations a nd e xplained p rocedures t o p atients

● Performed r adiographic e xaminations u sing s pecial l ow d ose t echniques, p osition p atients, s elect and s et t echnical f actors a nd a djust e quipment p arameters t aking i nto c onsideration p hysical differences i n p atients a nd m ake e xposures n ecessary f or t he r equested p rocedures u sing d igital radiographs

● Collected m edical i nsurance i nformation, v erified m edical b enefits, c o-pays, a nd d eductibles f or collection o f p ayments

● Assisted p atients w ith w orkers c ompensation p aperwork Santa C larita I maging

Kantor O rthopedics

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X-ray T echnician I nternship N ov. 2 009 - M ar. 2 010

● Prepared p atients f or r adiology e xaminations a nd e xplained p rocedures t o p atients

● Administered r adiographic e xams a nd f ilm d evelopment

● Perform radiographic examinations using special low dose techniques, positions patients, select and set technical factors and adjust equipment parameters taking into consideration physical differences i n p atients a nd m ake e xposures n ecessary f or t he r equested p rocedure.

● Assure that sterile supplies, local anesthetics, contract materials, catheters, and other required equipment a re p resent a nd l aid o ut.

● Performed d irect c lient s ervices i ncluding a dministering m edicine t o s ick a nd i njured p atients, recording v ital s igns, g athering a nd p rocessing l aboratory s amples a nd c arrying o ut o ther authorized m edical t ests a nd p rocedures

● Acted a s a l iaison w ith e xternal a gencies a nd f acilities t o i mplement b eneficial s ervices a nd programs

● Prepared p atients f or e xaminations, t reatments a nd o ther m edical p rocesses

● Performed i ntake o f p atient h istories a nd e xplained s pecific e xam d etails

● Positioned p atients a nd c ontrol x -ray e quipment t o c reate r adiographs o f d esired b ody p arts G.B. D ata S ystems, I NC, M arina D el R ey, C A American O ffice C enters, W estwood, C A

Executive A ssistant 1 997-2000

● Promoted w ithin 3 m onths f rom r eceptionist t o a dministrative a ssistant t o e xecutive a ssistant

● Provided h igh-level a dministrative s upport t o c hief o perating o fficer o f d irect m ail m arketing company, 1 2 e xecutives o f s uite

● Organized d octors’ c onference e vents, s cheduled t ravel a nd p lanned d aily i tineraries

● Assisted e ditor w ith r evisions o n a rticles f or j ournal u sing M S W ord

● Coordinated p rojects a nd e vents e xercising t he a bility t o i mprovise, i mprove p rocedures, a nd m eet demanding d eadlines

● Handled c alls a nd p romptly f orwarded t hem t o a ppropriate p ersons f or o ver 1 2 e xecutives o f s uite

● Planned a nd c oordinated m eetings a nd l uncheons

● Organized t he d etails o f s pecial e vents, t ravel a rrangements, c orporate a gendas a nd i tineraries

● Acted a s l iaison b etween c lients a nd E xecutives

● Maintained c lient p rofiles i n d atabase f or c urrent a nd n ew c lients

● Consistently d emonstrated s trong a ttention t o d etail a nd h ad t he a bility t o m ultitask i n a h igh p aced work e nvironment

● Handled a ll o fficial c ompany c orrespondence e fficiently

● Upgraded a ll o ffice f iling s ystem

Saturn o f S anta C larita, S anta C larita, C A Inventory C lerk 1 995-1997

● Promoted w ithin 3 m onths f rom r eceptionist t o c ashier t o i nventory c lerk

● Maintained d atabase o f n ew a nd u sed c ar i nventory f or t he d ealership

● Handled c alls a nd p romptly f orwarded t hem t o a ppropriate p ersons a mong 8 5 e mployees

● Answered q uestions a bout b usiness a nd o ffered b rochures w ith b usiness i nformation

● Assisted c lients w ith t aking p ayments f or s ervices r endered

● Verified d aily c ash r ecords f or a ccuracy a nd p osted r ecords t o t he a ccounts p ayable d epartment

● Assembled p aperwork f or d ealer r ental p rogram a nd c ompleted c ustomer a greement c ontracts 5 o f 4

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● Assisted i n a dditional a dministrative d uties t o e nhance t he c ohesiveness o f t he o ffice 6 o f 4

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