Gale M. Griffith

aduntq@r.postjobfree.com 602-***-****

Professional Summary:

I have 10 plus years within HealthCare in various settings Health Information Management, Utilization Management, Collections, and Claims.

Acute, Skill Nursing /LTC and Corporate.

I have held management, supervisory and team lead position.

Analytical and detail-oriented professional with strong communication interpersonal and time management abilities.

Technical Skills:

Multitasking

Proactive, Resourceful/Troubleshooting

Problem-solving and Decision making.

Medical terminology, ICD 10, CPT and HCPCS Codes.

Medicare, Medicaid, and Commercial Insurance.

Understanding of HIPPA rules and regulation.

Electronic Health Records (EHR) Electronic Medical Records (EMR)

BLS Certificate Expire 2024

PROFESSIONAL EXPERIENCE

MMC Group for Maximus Inc./California EDD Los Angeles, CA

Benefit Audit Processor 02/2022 – Current

Remote

Process 10-12 cases a day, increase my case load within two months.

Review and process benefit audit form for any missing information and discrepancies of wages from employer or employee to make a logical decision.

Assessing the information against requirements based on UI Code, Policies, and Procedures

Sending employers standard forms to obtain additional information or clear up a discrepancy Working closely with subject matter experts to gain further understanding of how to address outstanding issues or identify when a claim needs to be escalated

Apple Care Management Group La Palm, CA

Clinical Inpatient Coordinator 01/2020 – 11/2020

Remote

Assist the Clinical Services Inpatient Nurse with the facilitation of the patient admittance process.

Collect data to utilize concurrent review and facilitation of discharge planning.

Follow up outreach, ordering DME/Home Health and other post-discharge outpatient services.

Prepare NOMNC’s and collect information for DENC’s.

Apply ICD 10 and CPT codes upon admission and discharge.

Apply CMS criteria and guidelines

Molina Healthcare - Long Beach, CA

Care Review Processor II 04/2019 – 10/2019

Use various computers applications, to ensure correct medical services authorization process. Answer telephones and gave information to callers from independent medical offices and /or hospitals, take messages, or transfer calls to the appropriate individuals.

Open, read, process, and route incoming various authorization request or other medical information to insure adequate medical review of the same.

Non-clinical Lead Position/internal otherwise not listed

Review work done by others to ensure that company format policies are followed, and /or recommend revision if necessary.

Train and assist staff with use of available resources, and guidelines for accurate authorization review process.

Process and completed other assignments related to medical services authorization requested as given by direct peers.

UCLA Los Angeles - Los Angeles, CA

Case Manager Coordinator 10/2017 – 04/2018

Supplies telephone, clerical, and data entry support for the Utilization Management team.

Supplies computer entries of authorization request/provider inquiries, such as eligibility and benefits verification, provider contracting status, diagnosis and treatment requests, coordination of benefits status determination, hospital census information about admissions and discharges, and billing codes.

Responds to requests for authorization of services sent via phone, fax, and mail according to operational timeframes.

Contact physician offices according to Department guidelines to request missing information from authorization requests or for more information as requested by the Medical Director.

Presbyterian Intercommunity Health - Whittier, CA

UM Coordinator/Team Lead 09/2014 – 08/2016

Supplies telephone, clerical, and data entry support for the Utilization Management team.

Team leads review daily census and distribute workload amongst the team and assist with making sure the daily workload was complete.

Supply computer entries of authorization request/provider inquiries, such as eligibility of benefits verification, provider contracting status, diagnosis and treatment requests, coordination of benefits status determination, hospital census information about admissions and discharges, and billing codes.

Responds to requests for authorization of services sent via phone, fax, and mail according to operational timeframes.

Contact physician offices according to Department guidelines to request missing information from authorization requests or for more information as requested by the Medical Director.

Kaiser LAMC - Los Angeles, CA

Utilization Management Assistant 08/2010 – 09/2014

Interacted with 40 Case Managers and vendors from health maintenance organizations, Home Health Care agencies, Skilled Nursing Facilities, Durable Medical Equipment Companies.

Utilize Epic software.

Responsible for Placing discharged patients to lower level of care such as Skilled Nursing facilities for sub-acute care and rehab facilities utilizing rules and regulation of Medicare, Medi Cal and HMO's, Processing Appeals and Reconsideration to Health Services Advisory Group (HSAG) for review of medical necessity of patient care per Medicare peer review, and maintain logs for Durable Medical Equipment and Appeals, Assist case managers with administrative tasks such as retrieving charts, filing, auditing charts, etc.

Maintain effective relationships with case management staff, physicians, nurses, ancillary staff, post-acute vendors, patients, and their families.

Health Service Advisory Group - Tempe, CA

Medical Records Supervisor 10/2011 – 06/2012

Supervised 21 employees support workflow and staff.

Responsible: For coordinating and implementing quality improvement for federal, state, and private organizations.

Medical records supervisor overseeing the department, training unfamiliar staff to request and process electronic medical records from providers offices, review for completion before uploading into the system for the Quality Improvement Organizations

Schedule staff for daily, weekly, and monthly workflow.

Ensured all work was compliant within regulatory guidelines Generate reports of how the process was working and if it needs improvement.

Utilize CRMIS software, Word, Excel, and Outlook.

EDUCATION:

Learning Medical Coding. LLC Certified Professional Coder Current

Rasmussen College Online RHIT Have Not Completed

Webster Career College, Los Angeles, GED/Business Administration 1984-1986 Diploma

PROFESSIONAL REFRENCE UPON REQUEST

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