Experience

Heritage Provider Network
• Medical Practices
• 100 - 200 Employee
• Supervisor

  • Feb 2009 - Present


Medical Claims

• United States
• Hospitals and Health Care

• Supervisor

  • Feb 2008 - Present

  Responsible for ensuring that claim inventories are processed within the timeliness guidelines set forth by the Department of Managed Healthcare and the Center for Medicare and Medicaid Services. Responsible for compliance and reporting to all health plans through annual audits and developing CAPs (Corrective Active Plans) as necessary. Personnel responsibilities include the completion of employee performance evaluations according to company directives, providing additional training and support as needed. Additional duties include managing the payroll/timesheet reporting system, employee time off requests, maintaining positive interdepartmental, provider and employee relationships. • Directly supervise staff of 18 including: claims examiners, customer service, compliance, auditors • Handle company-­‐wide health plan and compliance issues as well as adjudication • Oversees Quarterly PDRs (Provider Dispute Resolution) that process for all 3 groups as well as Part C (Senior Claims) for all 3 groups • Oversees yearly audit to ensure compliance as well as sets up CAPs (Corrective Action Plans) to fix any issues • Oversight of roughly 60,000 claims on a monthly basis between all 3 groups • Very thorough knowledge of Senior and Commercial lines of business; limited experience with Medi-­‐Cal • Very familiar with ICD-­‐9 and CPT codes; limited exposure to ICD-­‐10



High Desert Medical Group

• United States
• Wellness and Fitness Services
• 1 - 100 Employee

• Recovery Specialist

  • Jun 2003 - Present

  Responsible for requesting and ensuring health plan reimbursement through the Eligibility Guarantee provisions outlined in the various contracts. Responsible for recovery based on Stop-­‐loss from third party insurers. Duties included submitting refund request letters to providers when an overpayment was identified. Developed and implemented the policies and procedures used for Eligibility Guarantee and Stop-­‐loss claims including employee training.

• Claims/Compliance Supervisor

  • Jul 2001 - Present

  High Desert Medical Group, is an affiliate of Heritage Provider Network—a recognized innovative leader in healthcare delivery networks in California for more than 30 years. Since the formation in 1982, HDMG has mirrored the reputation of the parent company by being at the forefront in providing residents of the Antelope Valley with the highest quality health care possible. With our newly relocated Heritage Health Care facility in East Palmdale, our full service HDMG-­‐Acton clinic in Acton/Agua Dulce, and now a brand new state-­‐of-­‐ the-­‐art Senior Wellness Center located near our main facility in Lancaster, HDMG continues to offer a fresh perspective and sound solutions to health care challenges.



Durable Medical Equipment

• United States
• Hospitals and Health Care
• 1 - 100 Employee

• Referral Coordinator

  • Jul 2001 - Present

  Responsible for verification of eligibility and benefits, preparing authorizations or denials based on health plan criteria. Duties also included coordinating delivery of equipment between the vendor and patients.

• Referral Coordinator

  • Jul 2001 - Jun 2003

  Responsible for verifying insurance eligibility and benefits, generating authorization approvals and denials utilizing health plan guidelines. Duties included coordinating equipment delivery with the vendors and patients.



Sierra Medical Group

• United States
• Medical Practices

• Referral Coordinator

  • Feb 1998 - Jul 2001

  Founded in 1984, SMG joined Heritage Provider Network in 2008. We have created an atmosphere of wellness by promoting the idea that health is a function of mind and body. We have diligently invested our time and resources in the development of programs and services responsive to the healthcare needs of today's patient, while adapting to the increasingly diverse needs of tomorrow's healthcare agenda. We emphasize the importance of getting to know you and your history to ensure that you receive the highest quality medical care.