Senior Analyst, Technical Configuration Information Management

• Dec 2022 - Present

Configuration Analyst

• Jun 2017 - Present

Provider Contract Specialist

• Oct 2016 - Jun 2017

• Quality Assurance review of contract agreements such as new provider contracts, amendments, letter of agreements and consent to assignments for PCP, Ancillary, Group/IPA, Hospital and Specialty Providers • Track contract agreement into our databases: CATS (Contract Agreement Tracking System) and ECMS (Emptoris Contract Management System)• Coordinate with Contract Negotiators for contract verification and any missing information • Ensure that a CCRF (Configuration Change Request Form) is submitted to the Business Analytics (BA) Department for processing and configuration in a timely manner• Prepare and submit New Provider Load spreadsheet to Provider Configuration Management (PCM) in an accurate and timely manner• Conduct review of provider and contract information loaded in QNXT for accuracy• Develop SQL scripts and create Adhoc reports using Microsoft SQL Server for member move, provider information and provider data clean-up

Provider Contract Coordinator

• Dec 2013 - Oct 2016

• Performs scanning and uploading of Letter of Agreements and Provider Contracts in Contract Administration Share Point• Processes and conducts review and research of Claims Workflow for Medicaid, Medicare, Market Place and MMP Line of Businesses.• Makes outbound call to the providers to verify billing information.• Cross-trained in reviewing Provider Contracts, sending the request to Provider Information Management Department using spreadsheet to load the provider information in QNXT• Processed provider and group’s request sent to CA Provider Information Management Mailbox (e.g. Provider add, demographic update and provider termination)

Inquiry D/A Coordinator

• Jun 2012 - Dec 2013

• Prepared grievance and appeals acknowledgement letter and grievance resolution letter. • Conducted review, research and investigation of the member complaints.• Communicated member grievances to the providers, vendors and internal departments for response and resolution.• Made follow-up on the grievance response and issue to ensure that the cases are resolved in a timely manner.• Handled Health Net request for information (PIR) to assist them with the resolution of the grievance and appeals and logs HN PIR.• Made outbound calls to the member to obtain additional information.• Processed Provider Initiated Disenrollment Request.• Performed other duties as assigned.• Assisted the PDR – Medicare Team in Waiver of Liability Calls.

Community Outreach Representative

• Apr 2011 - Jun 2012

• Performed outbound calls to remind our members about the renewal/redetermination of their medical benefits.• Assisted members in filling out the Medical Renewal Form over the phone for state of Washington.• Assisted members in contacting their case worker/eligibility worker for state of California.• Answered phone calls from members we called through IVR system to remind and assist with their renewal/redetermination paperwork.• Prepared the list of Medical Renewal Form for Washington members to be faxed to DSHS• Provided eligibility and benefits information to providers specifically for state of California and temporarily for state of Texas.

Eligibility Representative - Member Services

• May 2007 - Apr 2011

• Handled provider and member calls regarding eligibility verification, provider change and other inquiries.• Processed member add, delete, demographic change, PCP assignment/change and update member’s eligibility in QNXT and pharmacy system.• Prepared and process member move notification letters.• Processed claims eligibility issue through eligibility claims workflow and eligibility CHDP report.• Updated member’s COB information through Co-ordination of Benefits file.• Made call to the other insurance carrier for coverage verification.• Coordinated provider’s issue such as PCP assignment, open panel request, member move, and affiliation verification to Provider Information Management department.• Processed dis-enrollment request.• Performed mid-month and month end process.

Office staff

• Jan 2005 - May 2007