Care Corrdination
Resume:
Jennifer Edwards
Los Angeles, CA
*************@*******.*** - 310-***-****
Authorized to work in the US for any employer
WORK EXPERIENCE
Senior Appeals Corrdinator
UnitedHealth Group - Cypress, CA - July 2012 to Present Coordinate with in-house government affairs team to champion legislative policies and practices that advance mission goals.
Research, analyze and ensure successful implementation of company best practices for Operations team. Work with the Brand Education Executive team on developing business plans, supporting company and group initiatives, assisting with change management, tracking key performance indicators Perform individual case review for appeals and grievances for various health plan and insurance products, which may include PPO, ASO, HMO, MAPD. The appeals are in response to adverse Clinical Administrative Case Review
UnitedHealth Group - Cypress, CA - 2012 to Present Hold accountability in attaining a 100% audit score for Employee and Individual unit on benefit documents assessment.
• Administer the accumulation of member admission and discharge information post-notification through collaboration with Hospital and Clinical teams.
• Ensure strict compliance with legal and regulatory requirements, including Health Insurance Portability and Accountability Act (HIPAA), healthcare reform, National Committee for Quality Assurance (NCQA), and Employee Retirement Income Security Act (ERISA).
• Provide keen oversight to productive processes for all utilization review governance, as well as boosting incoming and outgoing referrals and prior authorizations.
• Spearhead the recruitment process, career advancement of staff, performance audits, and interpretation of policy plans.
• Effectively function as member of self-directed team to attain individual and team performance metrics.
• Exemplify expertise in conveying all types of benefit determinations and decisions including coverage guidelines, contractual limitations, and reimbursement determinations.
• Work in partnership with health care providers and members through phone discussion regarding benefit coverage and medical determinations for the acquisition of clinical information. ADMINISTRATIVE ASSISTANT, PEDIATRIC AND OBGYN DEPARTMENT Spherion Staffing Agency/ UCLA Medical Center - Westwood, CA - 2010 to 201*-****-****
• Guaranteed the sustainability of patient's finance and account for incoming and outgoing insurances.
• Assumed full responsibility in handling bill insurance claims and code as necessary; collecting authorizations for patient visits; and contacting insurance companies for eligibility and coverage.
• Performed comprehensive research to effectuate a budget focusing on yearly and future needs.
• Carried out the preparation of graphs, charts, and statistical information for data analysis. PATIENT FINANCIAL SERVICES, ADMISSIONS REPRESENTATIVE Cedars-Sinai Medical Center - Beverly Hills, CA - 2008 to 2010
• Maintained active involvement in gathering present information from new and existing patients.
• Encoded and updated patient's medical information into the healthcare practice system.
• Took full charge of identifying payer source and filing of correct pay type; validating insurance eligibility; and acquiring authorizations for dates of service and financial status.
• Generated appropriate notations through the use of Electronic Health Record/EMR and Practice System. 1 Page
• 1309 West 82nd Street, Los Angeles, California 90044 • 310-***-****• ************@*****.*** ADMINISTRATIVE ANALYST
UCLA Health, Orthopaedic Surgery - Westwood, CA - 2005 to 2008
• Demonstrated leadership skills in mentoring and coordinating staff for performance policies and procedures.
• Rendered direct supervision in auditing and partnered with the department manager for in-depth data evaluation and accurate projections by utilizing established business techniques.
• Performed various administrative and technical functions such as delegation of tasks by employing strong analytical skills.
Physician Support Services
UCLA - Los Angeles, CA - 2004 to 2005
Held accountable for staff reimbursements for the clinic offices and administration, which involved scrutinizing payment request invoices, funding, and vendor payment history to recognize duplicates. PATIENT FINANCIAL SERVICE REPRESENTATIVE
UCLA Medical Center-Orthopaedic Surgery Center - Santa Monica, CA - 2003 to 2004 MEDICAL RECORDS TECHNICIAN
Century City Medical Center - Century City, CA - 2001 to 2003 EDUCATION
BACHELOR OF SCIENCE in HEALTHCARE ADMINISTRATION AND MANAGEMENT University of Phoenix - Gardena, CA
2015
MASTER OF BUSINESS ADMINISTRATION in ADMINISTRATION AND MANAGEMENT University of Phoenix - Gardena, CA
SKILLS
Medical Terminology, Emergency Medicine, Public Health, Data Analysis, Healthcare Information, Revenue Cycle management, Medical Compliance, Staff Recruitment and Leadership, Clinical Operations (10+ years), Microsoft Office (10+ years), Microsoft Excel (10+ years), Project Management (10+ years), Microsoft Access (10+ years), Microsoft Outlook (10+ years), Employee Relations (10+ years), Microsoft Powerpoint (10+ years), Emr (10+ years), EHR (10+ years), Interpersonal Skills (10+ years), ICD-9 (10+ years), Data Entry (10+ years), Training (10+ years), Typing (10+ years), Time Management (10+ years), Team Leadership (10+ years), Business Analysis (10+ years), Customer Service (10+ years), Computer Skills (10+ years), Computer Literate (10+ years), Data Entry (10+ years), Database Management (10+ years), Dependable (10+ years), Financial Analysis (10+ years), Financial Services (10+ years), Financial Reporting (10+ years), Healthcare (10+ years), Hipaa (10+ years), Kronos (10+ years), Leadership
(10+ years), Auditing (7 years), Organization (10+ years), Project Management (8 years), Problem Solving (10+ years), Public Speaking (10+ years), Peoplesoft (8 years), Quickbooks (8 years), Quality Assurance (8 years), Reporting (10+ years), SQL (7 years), Scheduling (10+ years), Sharepoint (8 years), Time Management (10+ years), Teaching (10+ years), Team Building (10+ years), Unix (6 years), User Experience (10+ years), Writing (10+ years)
ADDITIONAL INFORMATION
QUALIFICATIONS PROFILE
Strategic and challenge-driven professional, offering comprehensive experience in clinical research, hospital organization, productivity development, and quality management. Equipped with proven ability in data management, process integration, utilization analysis, as well as profitability and efficiency studies in patient quality care. Effective at coordinating with executives while ensuring compliance with various healthcare regulations. Skilled at performing superior service in outpatient settings for diverse individuals. Armed with strong communication and critical thinking aptitudes. AREAS OF EXPERTISE
Medical Education Emergency Medicine Public Health Data Analysis Healthcare Information Revenue Cycle Management Medical Compliance Staff Recruitment and Leadership Clinical Operations
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