Bruce Bowen

Interview Availability: ** Hours prior notice, can start as soon as possible

Summary: Email Address ad1zzr@r.postjobfree.com. Cell Number 661-***-****

Professional Lead Appeals Grievance Coordinator / Senior Claims Examiner/ Grievance Examiner who has over 10+ years of experience in the Medical/ healthcare field and 10+ years of experience in Grievances and Appeals.

Well-versed in monitoring the day-to-day production for Grievances and Appeals (G&A), Compliance, Quality, & Production.

Strong experience in writing letters to members and providers.

Responsible for review and investigation of assigned standard and/or expedited grievances and appeals, including quality of care complaints, to provide timely and accurate resolution to Plan enrolees.

Responsible for the development and maintenance of the G&A policies and procedures, workflows, member correspondence, and training as needed, or on an annual basis.

Hands-on experience in performing complex and routine quality audits in appeals using databases to verify completeness, accuracy, and adherence to regulations and compliance.

Familiar with researching, verifying, and interpreting vendor contract terms, interpreting EOBs, auditing rebate billing reports, medical claims, and payments, adjusting medical disputed claims, as well as conducting prejudicated.

Experienced in creating written correspondence letters to provide resolution to complaints when verbal contact cannot be made with the complainant.

Strong Knowledge of Commercial, Medicare, and Medi-Cal (Medicaid) processing, regulatory, Medical Terminology, Provider appeal, and compliance guidelines.

Preparing response letters to providers and members.

Experienced with Medical/Medicare/Commercial Claims Adjudication.

Proficient in MS Office, (Word, Excel, PowerPoint EPIC IDX ECAP QNXT PEGA system.

Critical thinking skills and writing skills.

Skills:

Medical/ healthcare field (10 years).

Grievances and Appeals (10 years).

Critical thinking skills and writing skills.

Write letters to members and providers.

Claims and payment methodology findings.

Medical Claims.

Medicare.

Medicaid.

Medical Terminology.

Provider appeal.

AB1500.

Process Implementation.

Data Analysis.

Policy Development.

Quality Improvement.

Provider appeal.

Cross-functional.

AB1500.

Regulatory Audits.

Regulatory Requirements.

Professional Experience:

Reason for the gap: Looking for a better project.

Lead Appeals Grievance Coordinator (Contract)

Cigna / Mind Lance (Remote)

Apr 2023 – June 2023

Write letters to members and providers.

Responsible for researching and resolving complex and/or escalated member/provider issues received from CMS (CTM complaints), Department of Insurance (DOI), Congressional offices, and escalating executive-level inquiries, etc.

Conduct a thorough investigation of complaints (CTMs) and escalated inquiries to accurately resolve the issues at hand and prevent future complaints from occurring.

Coordinate with internal stakeholders and all business units in developing and distributing written compliance policies and procedures including updating and proposing changes to the policies.

Responsible for assigned caseload which requires timely follow-up to ensure completion of cases within tight frames to meet internal and CMS expected goals.

Demonstrate the ability to problem solve, identify root causes, and make the proper recommendations to correct the root cause of the issue/complaint.

Make outbound calls to gather information and/or communicate the resolution to the appropriate party regarding the member/provider complaint.

Responsible for the development and maintenance of the G&A Policies and Procedures, workflows, member correspondence, and training as needed, or on an annual basis.

Create written correspondence letters to provide resolution to complaints when verbal contact cannot be made with the complainant.

Document all case research notes and resolution actions, in the appropriate systems, within the required time frames.

Communicate with other departments, when necessary, to resolve member/provider issues.

Know the formal and informal departmental goals, standards, policies, and procedures, which includes familiarity with other departments within the organization that allows him/her to identify workflow efficiencies and process improvements across the organization.

Display a positive attitude and report problems and issues to management as appropriate.

Handle other duties and special projects as assigned, such as the Customer Advocacy Support Team, (CAST) project.

Senior Claims Examiner/ Grievance Examiner (Direct Hire)

Molina Healthcare, Remote

Sep 2022 – Apr 2023

Audit medical claims by contacting patients, hospitals, and doctors to make sure procedures were completed and the medical cost was correct before payments were made.

Analyze and audit the reports to look for correct payments and make sure codes are correct.

Maintain an understanding of policies and procedures governing credit balances and resolutions.

Monitor the day-to-day production for Grievances and Appeals (G&A), Compliance, Quality, & Production.

Responsible for review and investigation of assigned standard and/or expedited grievances and appeals, including quality of care complaints, to provide timely and accurate resolution to Plan enrolees.

Reason for the gap: Looking for a better project.

Grievances & Appeals Coordinator Pyramd Consulting May 2022-August 2022

HealthNet, Remote

Write letters to members and providers.

Audit medical claims by contacting patients, hospitals, and doctors to make sure procedures were completed and the medical cost was correct before payments were made.

Analyze and audit the reports to look for correct payments and make sure codes are correct.

Maintain an understanding of policies and procedures governing credit balances and resolutions.

Monitor the day-to-day production for Grievances and Appeals (G&A), Compliance, Quality, & Production.

Provider Dispute Specialist/ Appeals & Grievance (Contract)

Blue Shield Health Plan/ Bluestone, Remote

Apr 2020 – Mar 2021

Research and evaluate contract terms/interpretation and compile necessary supporting documentation for the resolution of provider-disputed claims.

Respond to incoming Provider Disputes accurately, timely, and according to all established regulatory guidelines.

Process, adjudicate, and notate claims accordingly within the Claim system.

Update the tracking system of Provider Disputes and appeals correspondence outcomes.

Identify denial or payment variance trends and escalate to department management as appropriate for training opportunities and corrective action.

Distinguish between a provider dispute and a provider appeal and generate and/or escalate a provider appeal for payment as appropriate and according to regulatory guidelines.

Review grievances and appeals for reconsideration and either approve or deny based on determination.

Review and prepare for medical review presentation.

Prepare response letters to providers and members.

Reason for the gap: Looking for a better project.

Lead Claims Auditor/Provider Dispute Specialist (Direct Hire)

Med Point Management (IPA), Los Angeles, CA

Jul 2017 – Jan 2019

Audit medical claims by contacting patients, hospitals, and doctors to make sure procedures were completed and the medical cost was correct before payments were made.

Analyze and audit the reports to look for correct payments make sure codes are correct and maintain an understanding of policies and procedures governing credit balances and resolutions of provider contracts with insurance companies.

Proven track record of maintaining overall claims inventory within regulatory compliance guidelines.

Senior Claims Specialist/Auditor/Provider Dispute Specialist

Health Care LA (IPA), Los Angeles, CA

Feb 2013 – Jun 2017

Perform prepayment audits on all types of medical claims Professional and Facility according to department contract, and regulatory requirements.

Process UB04 and HCFA/1500 claims and adjusted medical disputed claims.

Verify and interpret information in all vendor contracts to resolve issues.

Update authorization information based on information obtained from providers.

Conduct pre-adjudicated claims and payment methodology findings and research errors.

Senior Collector/Lead

Mammoth Hospital, Mammoth Lakes, CA

May 2012 – Sep 2012

File, bill, and collect on high-dollar Commercial and Government appealed, underpaid, and litigation claims promptly using MS4 systems.

Supervise up to 15 employees in a managed care environment, with various size teams of medical Claims and Clerical staff.

Monitor claims production and performance, and assign work to staff members to ensure timely and accurate payment of claims.

Provider Healthcare Agent

ACS Xerox, Los Angeles, CA

May 2011 – Apr 2012

Responsible for high-volume telephone claims status updates about Medical, CCS, and other Government-related claims submitted for payment.

Adjudicate claims, appeals, CCS, SARS, TARS, and denials.

Process claims, appeals, CCS, CHDP, CIF, and patient eligibility.

Receive inbound phone calls from providers regarding claims and payment status, such as Medical, CCS, CHDP, and GHPP.

Senior Financial Services Representative/Lead

Cedars-Sinai Medical Centre, Los Angeles, CA

Jul 2002 – Dec 2010

File, bill, and collect on HMO, PPO, Medicare, CCS, Transplant Accounts, and Medical Managed Care using IDX and EPIC systems, initiate appropriate follow-up to ensure optimum reimbursement.

Adjust and appeal accounts where improper entries were posted, with accurate and correct calculations, and complete documentation to support action taken or requested.

Process claims and refunds to insurance companies.

Interpret and discuss insurance explanations of benefits (EOBs) and payments.

Research and analyze data to address operational challenges and customer service issues.

Develop and maintain positive customer relations and coordinate with various functions within the company to ensure customer requests and questions are handled appropriately and promptly.

Research and provide resolution of hospital and provider billing, and research disputes with carrier and IPA claims payments for Hospital and medical claims submitted on CMS 1500 and UB04 claims forms.

Education:

High School Diploma, David Starr Jordan High School Los Angeles, CA, Jun 1972.

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