Administrative Assistant Medical Review
Resume:
Samia Soliman
Santa Clarita, CA 91390
661-***-**** (C)
Professional Summary.
Employment & Work experience:
**** - ******* **** ***** ******* Group (prior authorization coordinator)
< Handle medical review on authorization form received from providers for all type of groups
HMO, PPO, Senior, Scan, etc.
< Contact provider requesting clinical notes and support documentation to process final reviews
< This includes sometimes ordering medical records and calling members and/or providers. Research leads to approve/deny recommendations.
< Routing authorization to medical reviewer for final review.
Blue Cross of California
2019 - with Major Group Underwriting (Underwriting Assistant)
> Handle medical review on individual enrollment forms for a small number of large association customers.
This includes sometimes ordering medical records and calling members and/or providers. Research leads to approve/deny recommendations.
Coordinate denies recommendations with a physician advisor. Generate written correspondence to providers, members and regulatory entities and organize, maintain hard copy files
> Handle all D&B reports including financial report
> Handle new/renewal vouchers and create suffix worksheet with rates
> Handle and a sign renewal/new cases on I Avenue to u/w
> Re-assign underwriting monthly work list
> Prepare Lag/CLR/Paid claims/enrollment reports for sales office
> Medical review large claims over certain thresholds using long term medical reviews expertise and communicates to the underwriters. Analysis the reviews with prognosis and create a special report with feedback of any ongoing claims using WGS and WMDS(Cetrix).
> Accepts special projects enthusiastically
> Processes all assigned funding and performance guarantee vouchers
> Handle escalated and unresolved issues
Blue Cross of California
1999-Present with Medical Review Department (Sr. Administrative Assistant)
Supported the SCR effort
Acting lead over a group of Administrative Associates
Provides direction and guidance to the team members
Handle escalated and unresolved issues
Provides quality control services such as case review/audit/training
Performs other duties as assigned, and performs special projects as assigned
Complete all assigned projects timely and accurately
Assist in coordinating team activities
Develop, recommend and implement training, including implements a job training manual
Handle and resolve PDR letters issues to meet regulatory timeframes
Handle grievance calls from members or providers on denied services in MSO department on SB59 (PPO) regulated cases
Requesting medical records
Sort and route claims issues to appropriate physician according to the claim specialty from ISG and Large group MRU
Prioritize all issues according to the due date, contract time limits (performance guarantee groups) and state mandates (SB59 & ERISA)
Track and report all claims issues to appropriate physician, on access database and Mainframe i.e Inquiry Tracking
Interpret and log physician’s decision on database and forward cases accordingly
Generate written correspondence to providers, members and regulatory entities and organize, maintain hard copy files
Involved in collaborating new processes in MRU
Skilled in medical terminology and MRU Medical Operational Guidelines & Procedures
Daily reports for ISG and Large Group
Daily production of letters, access updates and phone calls
Assists supervisor/manager with special project including MRA’s/Admin’s production, and provide quality control to completed files. Develops, recommends, and implements training to enhance department production.
Assists and provide research outcomes and recommends process improvement solutions.
1994-1999 with Grievance & Appeals dept. (Administrative Assistant)
Handle grievance calls and correspondence from providers and members on services denied by BCC
Prepare cases for nurse/physician review. This included pulling member’s contract benefit, related medical records and previous physician reviews
Sort all claims issues according to the claim specialty i.e. Surgery, Internal medicine, Ob-Gyn, Dermatology, etc received from ISG and Large group MRU
Generate acknowledgement and final decision letters to members and providers
1987- 1994 with Newberry Watch and Jewelry (Sales Manager)
Supervise sales associates and assist in sales transaction
Order and manage inventory
Maintain client relations
1999 -Real Estate Agent Present
With KW VIP properties Valencia
Selling over 40 properties in Los Angeles County, Listing, and Leasing.
2018, LIFE & Disability insurance License.
Education & Licensure
1998 to 1999 - Medical Insurance and billing & Medical Terminology (Learning Tree University)
1994 to 1995 - Microsoft Windows applications i.e. Word, Access, PowerPoint, Excel
1980 to 1982 - Diploma from University of Abasia, Egypt
1977 to 1980 - High School Diploma from Holleopelis, Egypt
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