Irma Zamora

** ***** ******* **** **********; * years Grievance and Appeals Coordinator

**** ******* ***, **** *

Orange, CA 92868

714-***-****

ady3z4@r.postjobfree.com

EXPERIENCE

Children's Hospital of Orange County -Orange, CA-

Grievance and Appeal Coordinator /Financial Coordinator- December 2015 - PRESENT

Analyze and resolve verbal and written claims, medical pre-service appeals, Part D pre-service appeals from both providers and members. Adhere to all federal, state and organizational regulations and policies and procedures pertinent to the review and processing of member and provider grievances and appeals.

Prepare cases for medical review as necessary.

Review grievances to identify potential quality or access issue and escalate for clinical review.

Draft and mail all provider and member grievance and appeals-related communications within the timeframes required by State and Federal agencies.

Conduct outreach to members and providers for additional information required to resolve grievance and appeals cases. This may involve placing outbound calls or sending faxes or emails.

Provide members and/or providers with status updates, upon request, regarding their open grievances or appeals

Collaborate with subject matter experts within the organization to obtain benefit and/or clinical opinions/interpretations of complex cases. Serve as liaison between member, provider regulatory agencies and internal sta .

Correspond with key individuals regarding grievance and appeal decisions. Altamed Health Services Corp. -Santa Ana, CA-

Lead Medical Assistant

July 2013 - November 2015

Administer ordered medications via, oral, topical, rectal, otic, ophthalmic and inhaled

Processes orders for medications and supplies in a timely manner Assist with onboarding and training new team members Verify insurance coverage and eligibility

Perform routine clinical functions under the supervision of a licensed provider/nurse

SKILLS

MS Office

Medical Records

Customer Service

Microsoft Excel

Data Entry

HIPAA Management

Communication

Customer service

Leadership

Project management

Research

Analytical skills

Teamwork

LANGUAGES

English, Spanish

Assist the provider in navigating the EHR/EMR

Locate information for review

Participates in team-based care and patient education initiatives to support the health and wellness of patients in conjunction with the LVN/LPN/RN

In conjunction with the Practice Manager, oversees the daily activities of the MA’s

United West Labs, Inc. — Santa Ana, CA

Front / Back o ce Medical Assistant

04/2012-07/2013 Santa Ana, CA

Monitor and track time and attendance in accordance with clinic policy Perform all of the duties of the Medical Assistant I and Medical Assistant II Directs, supervises and coaches front o ce and clinical sta daily Directs less experienced medical assistants to specific duties such as obtaining vital signs (height, weight, blood pressure, ) and phlebotomy services as needed

Accompanies patient to exam rooms when necessary

Verifies insurance coverage and patient demographics Training of new and less experienced MSA's

Consult triage

Providing guidance to sta members to include change in policies and procedures

EDUCATION

Santa Ana Community College, Santa Ana, CA

AA Degree- Business Administration 2023- Present

American Career College Anaheim, CA

Medical Assistant Certificate, 2011

Valley High School High School

High School Diploma, 2010

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