Provider Disputes Resolution

NATASHA L. PETERSON

Cell: 805-***-**** E-mail: *****************@*****.***

SKILLS/CERTIFICATIONS:

WPM: 65; Meditrax Medical Software

Certification in Coding – 10/2011, Knowledge of CPT and ICD-9

Medical Terminology, BLS/PALS/Fire & Safety Certification - American Heart Association

Excellent C-IV skills: Microsoft Project

Excellent audit and case review capabilities

Excellent written and oral communication/presentation skills

Negotiation and conflict resolution

In-depth knowledge of the Social Services regulations for Adult Services and DHS/Children's Services Programs.

3M Infection Prevention Respiratory Protection Program

Computer Software- Microsoft Word, Excel, PowerPoint, Outlook, Lawson, Access, MEDITECH,

HCA Atlas, Visual CACTUS/OFFICE ALLY/Secure IMS Link, MHC

Certificate of Project Management

Certified Paralegal

PROFESSIONAL EXPERIENCE:

L.A. CARE HEALTH PLAN, Los Angeles, CA March 2011 - present

Project Specialist/Claims Dept.

Review case records and related documents, with particular reference to issues under appeal to determine course of action, based on research of applicable laws, rules, regulations and policy and procedures. Work with staff, appellants, legal providers/attorneys, and authorized representatives to obtain information and clarify department's actions pertinent to case resolution. Evaluates all data associated with the appeal process to determine compliance or exception to applicable statutes, regulations, and policies; when appropriate resolve issues diplomatically. Offer recommendations and resolve problems/issues which may include possible adjustments or stipulations to resolve appeals and presents these agreements to management. Processing of incoming PDR’s via certified mail, USPS, faxes, emails and all other sources of delivery methods. Identify and correctly route provider issues to the following departments, G&A, UM, Medical Management, claims production floor and the PDR unit. Utilize MHC to identify original claims being disputed by the Provider using the Provider dispute resolution process according to AB1455. Responsible for keying PDR’s into SSO system. Follow-up with provider regarding requested information and waiver of liability request forms that are sent on Medicare members. Currently supervise a staff of 7.

Work with Medical Management to resolve cases that are returned from Medical Management either miscoded or misdirected. Maintain claim files, such as records of settled claims and an inventory of claims requiring detailed analysis. Verify and analyze data used in settling claims to ensure that claims are valid and that settlements are made according to company practices and procedures. Examine claims investigated by insurance adjusters, further investigating questionable claims to determine whether to authorize payments. Present cases and participate in their discussion at claim committee meetings.

WEST HILLS HOSPITAL & MEDICAL CENTER Jan. 2010 –Feb 2012

Occupational Health Assistant/Infectious Disease Coordinator

Under the direction of the Nurse Practitioner established and managed occupational/employee health

program services and assist with developing in-house clinic for the hospital. Administered subcutaneous

injections to doctors on staff and hospital employees.

Provided administrative support to NP (nurse practitioner), Physician’s Assistant (PA); screened and

prioritized phone calls and appointments; routed inquiries to other levels of the organization as

appropriate.

Created, updated and managed the Employee Health Manual for the company. Worked closely with Nurse

Practitioner to manage flu clinic during flu season. Collaborate with other members of the occupation

Health team to maintain a safe and healthy work environment.

Refer patients to direct medical care providers specializing in work-related injuries/illnesses. Worked

closely with WC (worker’s compensation) insurance carrier for case management of employee injury,

exposures & needle sticks. Worked with departments to manage transitional duty programs and

coordinate safety/prevention measures.

Supervised staff of 10 employees; prepared reviews and made recommendations for promotion. Verified insurance/authorizations, prepared worker’s compensation claim forms and maintain confidential medical records for all hospital employees & contractors.

Handled Special Projects in the ER as well Patient Registration in the Emergency Roon

Maintained OSHA log & adhere to all governmental follow-up requirements.

Established and maintained filing system and records for the hospital. Prepare slides and charts, research, gather, sort, compile, and organize information for all hospital staff.

HEALTH NET, INC. Jan. 2008 – Dec. 2008

Grievance & Appeals Coordinator

Completed acknowledgement, resolution and/or extension letters for member and provider appeals and

Grievances in accordance with CMS or timeliness regulations. Applied CMS rules/regulations, ICD-9, CPT/HCPCS coding and all other applicable regulatory or statutory regulations to resolve member and provider appeals and grievances.

Independently researched, investigated, resolved and documented member and provider appeals and grievances in accordance with, CMS regulations. Updated appeal case files and Access databases during the course of an appeal in a timely and accurate manner. Performed other related responsibilities as assigned including compilation of appeal reports, all plan staff training, etc., as necessary.

ANTHEM BLUE CROSS (Kelly Services Agency) Sept. 2007 – Jan. 2008

Executive Assistant to VP Operations

Managed heavy calendar, scheduled meetings, travel arrangements and video conferences.

Performed credential verifications, sent re-credentialing applications, conducted document research

Collected, updated and maintained files in relation to credentialing of network providers, including application, contracts, current physician licenses, DEA licenses, malpractice insurance, board certifications and other forms.

Prepared and submitted applications to manager, medical director and credentialing committee for review.

Received Managed Care and PPO provider applications and re-credentialing applications.

Provided administrative support including generating and distributing mailings and scheduling meetings for VP Operations.

NL Peterson Realty, Inc. Nov. 2004 - Sept. 2007

Owner/Operator – Licensed RE Agent

Advertised, marketed, scheduled walk-thru and open house events for properties being sold by primary agency. Scheduled repairs and hired vendors to boost curb appeal of properties for sale. Worked with home inspectors, title insurance companies and served as a mediator between buyers and sellers at closings, assisted in preparation of legal documents for short sales of hard to sell properties/

Partnered with the City of Los Angeles on “Renovate Metropolitan Los Angeles Project” to rejuvenate downtown areas.

Amgen, Inc. June 1994 – Nov. 2004

Administrative Coordinator/Patent Administrative Coordinator

Provided administrative and staff support. Prepared and maintained legal reports and records regarding operations, changes in staffing levels, status and tracking of projects, new products and services liaison with bookkeeping/accounting firm to manage invoicing and vendor payments.

Managed heavy calendar, scheduled meetings and video conference calls. Handled all incoming and outgoing calls for Vice President. Organized and distributed legal contracts, interfaced with research, contract administration, and neuroscience teams.

Monitored calendars, depositions, court appearances and documented due dates. Served as administrative liaison with vendors externally for purchasing, staffing, facilities, travel, meetings and conference room issues.

EDUCATION:

Argosy University – Major: Psychology, 2/2015

Thousand Oaks Career College, Medical Assistant – 3/2011

Ventura Community College – 7/2010

Paralegal Degree, Merit College – 6/2001

Licensed Real Estate Agent – Since 1999

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