Experience

Modivcare

• United States
• Hospitals and Health Care
• 700 & Above Employee

• Provider Relations Director

  • Nov 2021 - Present

• Provider Relations Manager

  • Sep 2020 - Nov 2021

• Provider Relations Coordinator

  • Aug 2020 - Sep 2020



Empire BlueCross BlueShield HealthPlus (formerly HealthPlus Amerigroup)

• Program Manager

  • Mar 2015 - Mar 2019

  Point-of-contact for all provider-facing communications at New York Health Plan Consultations with business owners to identify communication objectives and recommend communication strategies Review of submitted materials to ensure they follow appropriate corporate standards and guidelines Transition of material to appropriate format if not submitted as such Identification and suggestion of content improvements such as use of plain language, grammar edits, etc. Final review of material prior to submission to appropriate review/approval body within the enterprise Tracking of status of reviews both during internal process and after submission to said review/approval body Notification of review status to business owners Tracking of communication release status and notification to business owners Research, review and edit of corporate and plan policies/procedures related to Provider Relations Serve as Provider Relations representative/contributor to a number of New York Health Plan committees and workgroups Show less


Empire BlueCross BlueShield HealthPlus
• United States
• Insurance
• 1 - 100 Employee
• Program Manager

  • Mar 2015 - Mar 2019


HealthPlus Amerigroup

• Network Services Manager

  • Mar 2014 - Mar 2015

  Plan, direct and control resources and efforts of staff of the Network Services unit. Obtain and manage resources to effectively and efficiently support operational needs and strategic initiatives. Ensure accuracy and timeliness of output and deliverables for assigned functional areas. Manage maintenance of provider information to ensure accuracy of provider demographic and billing information and manage service issues. Report project and progress statuses to Senior Management. Hire, train, coach, counsel and evaluate performance of direct reports. Show less



AlphaCare of New York, Inc.

• Insurance
• 1 - 100 Employee

• Manager, Grievance and Appeals

  • Sep 2013 - Nov 2013

  Creation of policies and notices relative to grievance and appeals procedures pursuant to New York State’s Memorandum of Understanding (MOU), Public Health Law and CMS regulations for FIDA and in preparation for launch of Medicare Line of Business Oversight of day to day operations of administrative staff to ensure regulatory compliance of grievances and appeals for the Managed Long Term Care Line of Business Chair of biweekly Appeal Committee meetings to discuss and complete pending MLTC appeals Review of grievances and appeals responses from assigned departments upon completion to ensure accuracy and compliance Development of staff including education on grievance and appeals processes for Medicare Line of Business Reports focusing on grievances and appeals metrics for MLTC Line of Business Show less



HealthCare Partners, IPA, MSO

• Team Leader, Quality Improvement

  • Aug 2012 - Sep 2013

  Assignment of appeals for review by Medical Directors (in EZ Cap system) including generation of weekly listing of reviews by MD with due dates Review of appeals upon completion by Medical Directors to ensure accuracy and compliance Auditing denial and appeal files to ensure quality and regulatory compliance as dictated by company contracts, CMS regulations and Public Health Law Review and preparation of documents for Administrative Law Judge hearings Monthly and quarterly reports focusing on denials and appeals metrics Creation of new and maintenance of existing denials and appeals policies to ensure regulatory compliance Oversight of administrative staff to ensure regulatory compliance relative to medical denials Development of staff including updating of workflows and processes Show less



Fidelis Care New York

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

• Medical Management Support Services Supervisor

  • May 2010 - Jun 2012

  Overseeing day to day operations of administrative staff to ensure regulatory compliance of appeal correspondence relative to medical denials Supervision of a team of six including submission of timesheets, scheduling of time off, yearly staff evaluations and providing performance feedback Training and development of a team of six including updating of workflows and processesAuditing appeal files and data entry of staff members to ensure quality and regulatory compliance dictated by Public Health LawDesigning and periodically updating various statistical reports and studiesPreparation and submission of Medicare appeals to MaximusGeneration of monthly and quarterly reports focusing on appeals metrics Show less

• Complaints & Appeals Associate

  • Aug 2009 - May 2010

  Reviewed member calls to determine nature of issue and categorize as either complaint or grievanceProcessed member complaints and grievances including investigation, outreach to members for additional information, and coordination with other departments including Claims for resolution of claims issuesGenerated and tracked all member complaints and grievances in log; maintenance of the log Generated letters and notifications of complaint and grievance outcomesPrepared and submitted Medicare appeals to MaximusComplaints, Grievances Show less



Affinity Health Plan

• United States
• Insurance
• 300 - 400 Employee

• Appeals Specialist

  • Sep 2007 - Aug 2009

  Processed member complaints including investigation, outreach to members for additional information, and coordination with other departments including Claims for resolution of claims issuesDocumented Member Complaint/Grievance software application, generation of all letters and notifications of complaint outcomesLogged and tracking of Fair Hearing requests and outcomesGenerated monthly and quarterly reports focusing on complaints, appeals and vendor metricsPresented complaints to the Complaints Committee for resolution and/or case study purposesMaintained tracking logs in Microsoft Excel Processed medical appeals and final adverse determinationsProcessed departmental mailTranslated documents from English to SpanishPerformed testing in Facets database during implementation of new procedures/processes Show less

• Appeals Assistant

  • Jul 2007 - Sep 2007

  Processed medical records received for appeals within the time frames dictated by Public Health LawDocumented determinations in CCMS DatabaseProcessed final adverse determinations in accordance with Public Health LawAssisted with generation and development of tracking logs in Microsoft Excel used to ensure adherence to Public Health Law regulations; maintained the same logsTranslated documents from English to SpanishMade outbound calls to providers and members to notify of determinationsProcessed departmental mailOther office duties as assigned Show less



Amerigroup Corporation, Healthcare Management Services

• Case Specialist/Denials Coordinator

  • Oct 2005 - Jul 2007

  Processed adverse determinations and appeals in accordance with Public Health Law Processed medical records received for appeals within the time frames dictated by Public Health Law Documented determinations in CareSTEPP, FACETS, and Macess Processed pharmacy denials in web based authorization system Created and maintained spreadsheet record of ER visits Referred records to the appropriate MD for review Compiled medical record information including detailed incidence of care reports upon request from the Member Privacy Unit Generated and submitted weekly and monthly reports Made outreach calls to facilities to confirm discharges Made outreach calls to members to inquire about emergency room visits and health outcomes Received calls from the Health Services queue for new authorization requests and inquiries regarding status of authorizations Verified member eligibility via EPACES website Translated outreach letters and official documents from English to Spanish Processed departmental mail; other office duties as assigned Show less



CarePlus Health Plan / Amerigroup Corporation

• Office Clerk

  • Jun 2005 - Oct 2005

  Ensured accuracy of QARR database claim records Filed, boxed, labeled and stored medical records in accordance with HIPAA law Packaged and mailed member records and claims for payment to appropriate parties General office duties as assigned Ensured accuracy of QARR database claim records Filed, boxed, labeled and stored medical records in accordance with HIPAA law Packaged and mailed member records and claims for payment to appropriate parties General office duties as assigned