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Customer Service Medical

Location:
Los Angeles, California, United States
Posted:
August 09, 2018

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Resume:

Craig C. Hudson

Los Angeles, CA

Phone: 310-***-****

Email: ac6l5m@r.postjobfree.com

Seeking a position in Compliance / Quality Management as an Appeals & Grievances Specialist, Credentialing Coordinator, Denial Letter Technician or Auditor.

SUMMARY OF QUALIFICATIONS

ADI time card processing for payroll, approval / denial of PTO request.

Handling of disciplinary actions regarding attendance and violation of company policies.

Over 15 years’ experience in the Health Care Industry. I come with Strong analytical skills and problem solving skills, while remaining flexible and maintaining excellent interpersonal and organizational skills.

Processing denial letters that are sent to Health Plan members as well as copies to the member’s doctor and a copy of the denial packet to the members Health Plan.

Processing of Appeals and Grievances, to include researching the case and going over my findings with my Medical Director, along with my recommendations.

Credentialing and re-credentialing of Health Care Physicians.

Daily Auditing and training of customer service reps.

Knowledgeable of HMO Guidelines, as well as Medicare and Medi-Cal regulatory compliance standards and guidelines, Health Plan eligibility and benefit verification

Daily and monthly monitoring of state and governmental disciplinary agencies and reporting my findings.

Efficient in presenting information accurately to Board of Directors, to include clear & concise explanations and documentation to go with my recommendations.

Strong written and verbal communication skills; I consistently am in communication with Medical Directors, Committees, Physicians, Upper Management, Vendors and Health Plans.

Ability to work independently and self directed while meeting goals/ deadlines

Efficient in MS Word and Excel.

PROFESSIONAL EXPERIENCE

UCLA Medical Group 02/2016-Present

Quality Management – Grievances Dept.

Receive complaints/Grievances directly from members and or Health Plans and investigate allegations, present my findings to the Medical Director and create closure letter.

Gather and prepare medical records for review.

Review or Input of referrals for compliance and correct coding.

Maintain daily logs and provider Quarterly reports to Board of Directors.

Implement and insure compliance of Corrective Action Plans with physician offices or vendors.

Prospect Medical Group (temp) 07/2015 – 10/2015

Credentialing Coordinator

Desk top audits and site audits of Physicians applications requesting to be Credentialed or Re-Credentialed as Scan Health Plan Physicians, verifying Licensure, Board Certifications, National Provider Data Bank.

Monitor Physicians who are on probation and implement monthly to yearly monitoring plan for the Provider Organization to assure the Physician is in compliance with terms of probation.

Monitor weekly/monthly Physician Licensures, law suits and disciplinary actions, Exclusions from the Office of the Inspector General and the California Opt-Out reporting.

Report all Adverse Actions to Chair of the Credentialing Committee, along with an explanation of occurrence and next course of action.

Monitor all Provider Organizations Delegated entities to assure they are following NCQA and CMS guidelines.

Site and desktop audits of the Provider Organizations Policies and Procedures, ensuring compliance with accrediting organization requirements.

Work closely with Provider Services to insure the Physician’s offices meet all NCQA guidelines.

LA CARE HEALTHPLAN 09/2014 – 02/2015

Supervisor of Referral Specialist

Conduct monthly 1:1 sessions with staff to review performance.

Communicate and identify disciplinary actions to ensure employee compliance with departmental objectives as well as policies and procedures.

Oversee and monitor overtime and maintain accurate accounting of each representative’s work performance on a daily basis.

Process time sensitive authorization and pre-certification requests to meet department timeframe and regulatory requirements when required.

Address escalated issued unable to be resolved by the Team Leads.

Adhere to regulatory turnaround times and standards and reinforcing to staff the importance of maintaining compliance with policies and procedures.

Develop compliance reports for employee training and development to assist in meeting department benchmarks.

Serve as subject matter expert on policies and procedures, as well as authorizations.

Provided consistent and direct feedback to staff regarding performance standards.

Oversee staffing, assignment distributions, and time off request.

Review UM hospital census and compliance reports and then inform staff of compliance standing.

Identify training needs including: development of programs, training materials, competency checklists, orientation checklists, and cross training staff.

Develop monthly activity reports for department leadership presentations.

Ensure HIPAA regulations relating to protection of personal history information are adhered to.

Supervised all day to day activities of the authorization department, I supervised 23 employees.

ALTAMED MANAGEMENT HEALTH SERVICES 02/2013 – 01/2014

Denial Letter Technician

Generate Pre-Service Denial Letters that are sent to the member, the physician and the Health Plan.

Maintain hard copies and electronic files of all denial packets generated per’ every 18 months.

Send secure copies of denial packets to Health Plans to be audited and then go over results with the auditor, then presenting those findings to the Committee.

Verify each case was denied correctly by the Medical Directors, based on the correct Guidelines or Benefits and presenting errors I find, as well as recommendations to the Medical Directors.

Creating postage and hand mailing a copy of every letter sent to the member within Turnaround Time, certified letters when applicable.

Track and Trend denial patterns by Medical Directors, Referral Coordinators and office staff and offer recommendations, which sometimes mean re-writing a Policy & Procedure.

SCAN HEALTH PLAN 07/2011 – 01/2013

Credentialing Coordinator

Desk top audits and site audits of Physicians applications requesting to be Credentialed or Re-Credentialed as Scan Health Plan Physicians, verifying Licensure, Board Certifications, National Provider Data Bank.

Prepare and submit recommendations regarding Credentialing and Re-Credentialing of Providers and Health Delivery Organizations, to the Credentialing Committee.

Monitor Physicians who are on probation and implement monthly to yearly monitoring plan for the Provider Organization to assure the Physician is in compliance with terms of probation.

Monitor weekly/monthly Physician Licensures, law suits and disciplinary actions, Exclusions from the Office of the Inspector General and the California Opt-Out reporting.

Report all Adverse Actions to Chair of the Credentialing Committee, along with an explanation of occurrence and next course of action.

Requesting the Medical Groups to monitor provider’s compliance with Court Orders and maintaining the reports received monthly from the Medical Groups.

Monitor all Provider Organizations Delegated entities to assure they are following NCQA and CMS guidelines.

Site and desktop audits of the Provider Organizations Policies and Procedures, ensuring compliance with accrediting organization requirements.

Work closely with Provider Services to insure the Physician’s offices meet all NCQA guidelines.

Primary point of liaison between senior management and Medical Groups.

ARCADIAN MANAGEMENT SERVICES 07/2010-07/2011

Quality Auditor of Customer Service

Monitor live and recorded calls of member services reps, provide feedback and training when applicable.

Train new hires on Quality of calls, benefit interpretation eligibility, authorizations, claims investigations and provider networks.

Report quality issues, coach the representative on what mistake was made create a file of training and maintain the file for all mangers of all call centers.

Create weekly reports for three call centers and distribute to all call center managers.

Take live calls from members and providers regarding benefits, eligibility, claims, etc. information.

Travel to other states for In House training of new hours when required.

Work directly with Medicare to investigate and resolve quality issues and create a Corrective Action Plan when needed.

Assist in creation and updates of Policies and Procedures for Customer Service dept.

Intake of escalated issues that are beyond the capability of the representative who takes the call.

Monitor open call logs and distribute for closure or close myself.

ARCADIAN MANAGEMENT SERVICES 03/2009-07/2010

DENIAL LETTER TECHNICIAN

Provide direct administrative support to UM Medical Director.

Process denial letters for Commercial, Medicare and Med-Cal members within regulatory standards and timeliness.

Provide daily log of received and processed denials, while identifying provider denial patterns.

Maintain functionality of Denial Wizard to ensure all health plan templates are up to date.

Ensure weekly and monthly health plan audits pass in at least 93% efficiency.

Create Corrective Action Plan for audits under percentile pass requirements.

PHYSICIANS ASSOC. OF GREATER SAN GABRIEL VALLEY 05/2002 – 02/2009

GRIEVANCE AND APPEALS SPECIALIST

Receive appeals/grievances from health plan; Log, create and maintain files.

Request medical records, review/arrange records and present to Medical Director for review.

Provide comprehensive investigation and timely response to member and health plan.

Implement Corrective Action Plans with physicians.

Generate authorizations to contracted, cost-effective Physicians and mail authorizations to member and health plan.

Create monthly reports of appeals/grievances.

UNIVERSITY AFFILIATES IPA 07/2000 – 05/2002

UTILIZATION MANAGEMENT COORDINATOR

Provide ongoing monitoring, facilitate and evaluate activities to address utilization patterns regarding pre-authorization request.

Generate authorizations to contracted Physicians within provider network within expected timeframes.

Perform eligibility and benefit verification with health plan.

EDUCATION1999-2000 MT. SAN ANTONIO COMMUNITY COLLEGE WALNUT, CA Some college coursework completed.



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