Experience

Mercy Care

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

• Ombudsman

  • Apr 2017 - Present

  *Advocate for members, investigate behavioral health concerns by working with members, family members, clinical team and internal departments to find resolution for Long Term Care members, Seriously Mentally Ill (SMI) adults, General Mental Health/Substance Use (GMHSU) adults and children on Medicaid and/or Medicare. •Build and maintain relationships with clinical providers and internal departments in order to work successfully in addressing and resolving member concerns while maintaining compliance with HIPAA. •Create and implement the member concerns investigative process.•Track and trend member concerns and system issues; report findings and make recommendations in monthly leadership meetings.•Member of Challenging Member Committee to review cases, develop care coordination interventions, promote continuity of member care and coordination of services by providing a single point of contact within the health plan, improve members’ appropriate utilization of services.•Review transportation vendor contracts, identify areas of improvement and make recommendations for contract changes, attend monthly meetings with transportation provider, address transportation issues for members and clinics.•Weekly transportation meeting with Veyo to address members on Critical Care Watch List. Monthly Joint Operating Committee meetings to address transportation concerns, identify trends, make recommendations to resolve member and systemic transportation issues.•Manage Clinic Advisory Councils - identify clinics needing technical assistance, identifying trends and making recommendations, monthly data reporting on attendance and trends•Complete annual Secret Shopper project for Clinical Operations team. Make all calls to SABG and MHBG providers, provide detailed notes in spreadsheet with detailed information, identify areas of concern, debrief with Clinical Operations team.



Oscar Health

• United States
• Insurance
• 700 & Above Employee

• Care Guide

  • Oct 2016 - Mar 2017

  *Work as part of a Concierge Team to help members navigate the complexity of the healthcare system, answering questions and resolving issues in collaboration with teams across the company. •Assist Director of Customer Relations with changing claims process to become more efficient and responsive. •Identify ongoing policy and procedural issues and provide improvement recommendations to leadership in order to enhance the member experience.•Educate members on their rights and how the healthcare system operates; empower members with plan information and advocate on behalf of members when interacting with Oscar departments, providers and third party vendors. •Assist in coordination of care across variety of settings such as ER, outpatient and home care. •Ensure confidentiality and compliance with HIPAA; educate members on HIPAA.•Investigate and resolve member issues regarding claims, billing, medications, DME, providers, third party vendors and network status.



Long Term Care Ombudsman

• Non-profit Organizations
• 1 - 100 Employee

• Certified Ombudsman Specialist, MyCare Ohio

  • Apr 2015 - Aug 2016

  * Educate, empower, and advocate for consumers in MyCare Ohio, a managed care program selected to coordinate the physical, behavioral, and long-term care services for individuals who are eligible for both Medicaid and Medicare.* Investigate complaints, mediate disputes, and negotiate resolution with plans and providers relating to benefits/access, enrollment/disenrollment, services, care coordination, DME, HHA, medication, and transportation.* Interface with Ohio Department of Medicaid, JFS, WRAAA, and managed care plans (CareSource, Buckeye, and United Healthcare).* Educate consumers about services, rights and protections under MyCare Ohio.* Advocate for consumers’ preferences; person centered approaches.* Analyze data and ensure quality standards are being met.* Identify systemic issues and opportunities for improvement.* Attend Member Advisory Council Meetings to educate consumers and identify ongoing consumer issues with managed care plans.* Kept current on Medicaid and Medicare changes.* Ensure confidentiality is maintained for clients, complainants, and Ombudsman matters per federal and state statues.* Knowledge of OAA; kept current on federal and state program laws and regulations, and regional program policies.* Attend continuing education at the State office in Columbus, Ohio.



The Centers for Families and Children

• United States
• 1 - 100 Employee

• Client Rights Officer and Service Integration Coordinator

  • Jul 2014 - Oct 2014

  * Advocate for clients; investigated Behavioral Health Program complaints and integrated Primary Care and Behavioral Health services by working closely with Primary Care, CPST, and Med / SOM staff. * Received, investigated, and resolved daily internal client complaints and grievances.* Identified patterns and made recommendations for procedural changes to improve staff-client relations.* Collected and analyzed data; identified findings and made recommendations to increase efficiency of agency processes by using the electronic medical record. * Assisted in development and coordination of activities related to client care.* Implemented the Consumer Connect Project, enabling over 2,000 (and growing) clients to access their online medical record. Created a training guide and trained staff on Consumer Connect.* Monitored staff to ensure Consumer Connect process accuracy and facilitated problem solving to the clients’ and agency’s satisfaction.

• Client Rights Officer/Performance Improvement Specialist

  • Mar 2013 - Jul 2014

  * Advocated on behalf of clients and parents, investigated complaints within Behavioral Health and Early Learning programs, and maintained compliance and quality assurance throughout all agency programs.* Received, investigated, and resolved client and parent complaints and grievances.* Identified patterns and made recommendations for procedural changes to improve staff-client and staff-parent relations.* Developed and strengthened relationships and communication with all levels of staff to work effectively as a team to resolve client complaints and grievances.* Monitored Behavioral Health processes to ensure they were performed accurately and made recommendations to improve agency processes.* Performed data governance activities within the electronic medical record.* Assisted in development, distribution, collection, and reporting of client satisfaction surveys, as well as participated in client experience initiatives. * Assisted in implementing Consumer Connect Project, enabling clients to access their online medical record.* Attended monthly Client Rights Officer meetings at the Alcohol, Drug, and Mental Health Services (ADAMHS) Board of Cuyahoga County.* Kept current on Client Rights Policies and HIPAA laws.* Served as a member of the Major Unusual Incidents Committee to review cases and provide findings to incidents requested by the ADAMHS Board.

• Enrollment Specialist & Project Manager

  • Feb 2011 - Mar 2013

  * Ensured Medicaid eligible consumers had access to needed behavioral health services.* Responded to requests for behavioral health services; screened potential clients for eligibility.* Maintained database and updated information to reflect the current status of cases.* Made daily phone calls with potential clients and consumers; interfaced with staff via e-mail.* Maintained awareness of other agencies and organizations for referral of ineligible clients.* Ensured low-income individuals and families had access to affordable health care insurance. * Screened callers for transitional insurance eligibility.* Scheduled appointments with consumers to gather and complete necessary paperwork.* Reviewed and submitted completed applications.* Maintained and updated consumer spreadsheet, enabling quarterly reports.* Responded to consumer questions; discussed arrears and / or termination options.* Held weekly meeting via phone with a Kaiser liaison; advocated on consumers’ behalf.* Translated information (English to Ukrainian).



Westfield Group/Westfield Insurance

• File Clerk Tracer/Claims

  • 2007 - 2007



Medina County Board of Alcohol, Drugs, & Mental Health

• General Office

  • 2006 - 2006