Financial Services Social

MARISOL ACOSTA

NY 917-***-**** adzjfp@r.postjobfree.com LinkedIn Profile

Bilingual G&A Specialist with extensive experience in areas of claims, enrollment, benefits, member contracts, medical terminology and ICD/CPT coding. Strong knowledge of various internal processes with a track record of developing innovative strategies to improve internal systems and maximize productivity and resources. Dedicated as a progressive supervisor supporting cross-functioning teams through mentorship, training, coaching, and providing career development guidance. AREAS OF EXPERTISE

Grievance & Appeals Processes Root Cause Analysis MS Office Suite

Best Practices & Compliance Leadership & Mentorship Salesforce

Internal Audits Performance Management Facets ACHIEVEMENTS

• Received 2 Spot bonuses and 3 Bravo awards for work excellence as a Grievance and Appeals specialist and supervisor

• Worked seamlessly with senior management teams in building a progressive and productive work environment

• Management of a high level of cases and ensures we were in compliance with regulatory deadlines

• Successfully trained and support up to 6 new hires while overseeing a department of 10 staff

• Continually exceeded performance goals and successfully processed 220 cases in first quarter prior to compliance deadline

PROFESSIONAL EXPERIENCE

EMBLEMHEALTH New York, NY

Supervisor, Grievance & Appeals – Regulatory Department 2022 – 2023 Oversaw day-to-day operations—ensuring adherence to department performance and maintaining operational efficiency. Consistently ensured the staff responds to all member/provider inquiries within stipulated timeframes and successfully maintained member/provider satisfaction and compliance. Worked with staff—improving performance by carefully monitoring attendance and completing performance reviews. Managed relationships with delegates (Beacon, HCP, CMO, SOMOS, EviCore) as well as other departments. Instrumental in implementing quality improvement strategies—improving effectiveness and efficiency of operations. Utilized working knowledge of all G&A areas to ensure the department is fully compliant with all governmental regulations.

• Identified/implemented root cause analysis of appeal issues—working with key business areas to resolve issues

• Assisted in leading/monitoring training for new staff members

• Reviewed Daily/weekly reports to ensure timeframes have been met

• Review audits on staff files to evaluate the performance

Senior Grievance & Appeals Specialist – Regulatory Department 2019 – 2022 Independently investigate and respond to written/verbal appeals submitted by members, employees, contracted and non-contracted providers, Department of Financial Services (DFS), Attorney General (AG), Department of Health (DOH), and Executive or Congressional branches. Review complex cases, analyze and summarize for senior management and regulatory entities related to Prompt-pay inquiries, complaints, administrative and utilization review appeals, second-level complaints, second-level administrative appeals, and expedited appeals for all lines of business. Made critical decisions regarding research and investigation to appropriately resolve all inquiries. Preparation of cases for medical and administrative review detailing the findings of the investigation for consideration in the plan’s determination. Made key recommendations on administrative decisions by preparing detailed case summaries and reviewing all applicable benefit/contract materials.

• Reviewed payments issued by the organization—ensuring that they are in compliance with Prompt Pay and CMS Regulations

• Completed responses in accordance with policies/procedures as well as regulations by NCQA, CMS, and NY

• Management of internal office administrative processes—overseeing areas of budgeting, training, and reporting

• Determined if interest is due based on findings and calculated the interest amount

City of NY Medical Claims Adjuster/ Senior Control Specialist 2016 – 2019

• Evaluated correspondence/telephone inquiries to determine if requests meet criteria for adjustment and processed full adjudications for all correspondence/telephone inquiries which require adjustments, ALGS letter generation, and exceptions resolution. Evaluate correspondence/telephone inquiries to determine the correctness and accuracy of payment. Evaluated inquiries from internal departments on behalf of members and providers as well as correspondence. Manually price claims utilizing appropriate rate files while considering the provider’s network and beneficiary’s insurance policy. Reviewed all accounting inquiries from providers, subscribers and internal departments. Managed all stop payment and reissues of misplaced/lost checks.

Government Assisted Programs -Medicaid/Family Health Plus/Child Health Plus Intake Specialist 2010 – 2014

• Management of various internal processes including maintaining confidential member-related documents while assisting with entering members’ payment information and keeping accurate records. Prepared/submitted member applications to the Local districts of Social Services and HR Administration for Medicaid/Child Health Plus and Family Health Plus Eligibility. Entered all decisions received from the Local Districts of Social Services and the Human Resource Administration in Market Prominence Daily. Prepared all documents for Audits and retrieved requested applications and member-related documents for research related inquires

EDUCATION

High School of Fashion Industries New York, NY

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