Experience

CenCal Health

• United States
• Insurance
• 100 - 200 Employee

• Payment Integrity and Recoveries Manager

  • Jun 2023 - Present

  Santa Barbara, California, United States

• Configuration Analyst & Claims Auditor

  • Mar 2020 - Jun 2023

  Santa Barbara, California, United States • Responsible for serving as the internal expert on Medi-Cal fee-for-service policies and procedures related to claims and benefits; • Increasing automation of pricing for claims based on CenCal provider contracts; • Performing audits to ensure proper payment and claims processing; • Interpreting Operational Instruction Letters (OILs) for CenCal Health staff; • Evaluating and testing of Medi-Cal pricing decisions and policies for adoption into the claims processing system.

• Audit & Recoveries Manager - Finance

  • Sep 2016 - Feb 2020

  Santa Barbara, California Area • Responsible for auditing internal claims processing systems and controls to ensure the claims system is configured correctly and claims are processed in accordance with contractual and regulatory requirements • Prepared reports on internal audits, identify trends and make recommendations for improving internal business processes to meet contractual and regulatory compliance • Identified, researched and resolved claims over and under payments resulting from processing, configuration or… Show more • Responsible for auditing internal claims processing systems and controls to ensure the claims system is configured correctly and claims are processed in accordance with contractual and regulatory requirements • Prepared reports on internal audits, identify trends and make recommendations for improving internal business processes to meet contractual and regulatory compliance • Identified, researched and resolved claims over and under payments resulting from processing, configuration or eligibility errors • Oversaw the development and maintenance of P&Ps regarding internal auditing and recovery procedures • Organized, prepared and submit reinsurance renewal package annually • Submitted monthly claim file to the reinsurance carrier, and verified correct claim reimbursement in conjunction with the reinsurance broker • Provided direction, supervision and training to Finance Audit & Recovery Team • Preparing, reconciling and submitting for payment various complex vendor invoices (reinsurance, mental health and pharmacy contracts) • Implemented numerous new programs and process improvements with an eye towards improving efficiency (Payment Integrity/Fraud, Waste & Abuse; Provider Preventable Conditions • Championed and implemented several company initiatives with the goal of improving job satisfaction and overall happiness (volunteer day, ambassador program, teambuilding day)

• Claims Reimbursement Adjudication Supervisor

  • Jun 2010 - Sep 2016

  Santa Barbara, California Area •Oversee that all regulations required by CenCal Health pertaining to the processes for claims are maintained and monitored; •Provide direction, evaluation and support for the twelve Claims staff I was responsible for; •Ensure staff is advised of all procedural changes in a timely manner; •Review production and verification statistics of the unit on a regular basis; •Oversee and assure that all claims sent for review are performed accurately and timely; •Conducted regular… Show more •Oversee that all regulations required by CenCal Health pertaining to the processes for claims are maintained and monitored; •Provide direction, evaluation and support for the twelve Claims staff I was responsible for; •Ensure staff is advised of all procedural changes in a timely manner; •Review production and verification statistics of the unit on a regular basis; •Oversee and assure that all claims sent for review are performed accurately and timely; •Conducted regular meetings with our processing vendor, Emdeon, to ensure accuracy and timely processing; •Review quality control audits with staff to ensure compliance within established department guidelines, policies and procedures; •Identify errors and deficiencies; developed and implemented corrective action and training plans for staff when necessary; •Prepared and conduct performance evaluations for all staff supervised on an ongoing basis; •Prepared and maintained payroll information for those staff supervised; •Attended both internal and external meetings when necessary; •Assisted with the creation and distribution of the weekly manual review reports; •Gather, analyzed, prepared and logged monthly statistical data pertaining to the Reimbursement and Document Control areas; •When necessary, participated in the interview process for the selection of qualified candidates for the positions I supervises; •Provide backup support for the Department Assistant when necessary; •Maintained processes and timelines required by AB1455 Claims Settlement Practices and DHCS Regulations


Central Coast Urgentcare
• United States
• Medical Practices
• 1 - 100 Employee
• Occupational Medicine Manager

  • 2008 - 2010


Roblar Occupational Medicine Group

• Clinic Manager

  • Apr 2006 - Apr 2008

  Santa Maria, California