Adriana Rosales
Oxnard,CA
Summary
Versatile healthcare professional with over 10 years of broad expertise collaborating with cross-functional internal and external clients. Analytical problem-solver driving innovative solutions for seamless compliance. Goal-oriented team leader and self-motivated team player with proven success accomplishing audit accuracy. Prudent decision-maker and highly disciplined quick learner with exceptional interpersonal, organizational and communication skills.
Overview
14
14
years of professional experience
1
1
Certification
Work History
Grievance and Appeals Analyst
Anthem, Inc. (Elevance Health, Inc.)
09.2020 - Current
- Reviews, analyzes, and processes complex and non-complex grievances and appeals for Large Group PPO Accounts in accordance with DHMC regulatory requirements while meeting stringent timeframes of 30 days.
- Reviewed, researched, and directed grievances and appeal causes to appropriate personnel, and followed up to ensure that resolution has occurred, and proper written and verbal communication of the decision has occurred.
- Utilizes guidelines and review tools such as NextGen, Solutions Central, Pharmacy Claims Systems (COS), and CA Mainframe to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize and route to nursing and/or medical staff for review.
- Analyzes and renders determination on assigned complex and non-complex grievances and appeal issues.
- Serves as a liaison between grievances & appeals and or medical management and service operations and other internal departments.
- Produce routine ad hoc reports on grievance, complaints, and appeal data from the grievance and appeal database.
- Gathered and verified all required customer information for tracking purposes.
Financial Operations Specialist, External Sales Compensation
Anthem, Inc. (via BC Forward)
02.2020 - 12.2020
- Performed financial operation analysis of external sales compensation team, and manually scrubbed data by applying Excel spreadsheets to calculate commission payments.
- Calculated compensation for sales agents’ multiple products, accurately processed inquiries, business transfers, agent record changes and new group audit set up for all regions.
- Analyzed and communicated issues with multiple departments such as licensing and credentialing.
- Identified opportunities and recommended solutions to system access for team members.
- Acted as key stakeholder for major initiatives including collaborating with and supporting senior-level operations eliminating backlog of business transfer backlog of over 800 items in less than seven months.
- Strong problem-solving and conflict resolution skills in developing financial operation analysis of external sales compensation team helping increase net efficiency by around 90% as a result.
- Interfaced directly with cross-functional teams across multiple departments to calculate compensation for multiple processes and set up group audits for all areas with average accuracy rates of 80% or better.
Performance Quality Analyst III, Sales Compensation, Licensing & Credentialing
Anthem, Inc.
10.2017 - 12.2019
- Facilitated, developed, and provided in-service training for peer auditors as necessary to address performance improvement opportunities and risk reduction strategies.
- Conducted routine audits and tracked trends audit results, to evaluate accuracy on sales compensation and licensing credentialing closed inquiries, and provided feedback to management.
- Enhanced performance, profitability, quality, and timeliness by managing multiple projects from start to finish and ensuring timely delivery of deliverables through the creation and implementation of improved processes.
- Functioned as an expert in sales compensation to analyze and consult on projects and served as a subject matter expert (SME) for discrepancy reviews, inquiries from the team, interpretation of guidelines, and audit processes.
- Efficiently prepared and briefed operational status reports, generated tasks in Jira for operational readiness items, and evaluated project teams Scrum boards in Jira.
- Established a collaborative culture by initiating business review meetings with production teams to identify operational readiness tasks for projects and ensure consistency, quality, and continuous improvement.
Compliance Coordinator, Corporate Compliance
Clinicas Del Camino Real, Inc.
05.2016 - 01.2017
- Oversaw corporate compliance operations and led training initiatives in healthcare clinics across Ventura County, serving as liaison between regulatory officials and clinic leadership to catalyze positive change.
- Improved audit preparedness, leading mock audits and reporting results to clinic leadership.
- Collaborated with clinic and pharmacy leadership to analyze performance, identify compliance issues, and implement strategic plans.
- Researched emerging healthcare regulations, maintaining procedural documentation in strict adherence to legal requirements; and conducted audits, including 340B audits.
- Championed improvements for centralized document submission processes to improve accuracy; and created new educational resources and tools to improve quality of employee training programs.
- Spearheaded a worksheet tool for compliance department processes reducing audit time by approximately 50% and increasing efficiency at health clinics by 90% as a result.
- Utilized training to conduct and train strong sources of urgency to stay abreast of constantly changing regulations through research and conducting 340B and regular audits with scores of 85% or better.
Compliance Audit Specialist, Medicare Compliance Sales & Marketing
Anthem, Inc.
09.2011 - 02.2015
- Directed implementation of audits and preparatory plans across 30+ sites, including sales call centers; and was instrumental to several major revisions of marketing materials targeting senior populations.
- Analyzed operations to determine compliance with Medicare regulations and developed actionable strategies to reach alignment with industry standards.
- Implemented numerous policies, training, and documentation improvements in collaboration with 30 managing general agencies to achieve compliance.
- Served as liaison between vendors, health plan advisors, and senior leadership regarding procedural changes and compliance goals.
- Enhanced internal communications, deploying new SharePoint sites to facilitate collaboration.
- Optimized annual employee review processes by creating trending reports for health plan advisors.
- Supervised audits and preparatory plans across 30+ sites and sales call centers.
- Maintained compliance of Medicare regulations including developing actionable strategies for alignment with industry standards.
- Prepared and presented reports for weekly compliance meetings.
- Assisted with revisions of marketing materials targeting senior populations.
- Improved annual employee review processes by creating trending reports for health plan advisors.
- Collaborated with 30 general agencies to develop improvements for numerous policies, trainings, and documentation.
Education
Bachelor of Science - Organizational Leadership
California Lutheran University
Thousand Oaks, CA06.2015
Skills
- Microsoft Office Suite (Word, PowerPoint, Excel, Access, Project), Jira, Confluence, SharePoint, Compass, CA Mainframe, Facets, Medisys, Salesforce
Certification
- Certificate in SAFe Agile
- Certificate in Project Management | Villanova University
- Business Analysis | University of Colorado Boulder
- Resident Insurance Provider | State of California
CORE STRENGHTS
- Healthcare Regulations & Compliance
- Quality Improvement & Project Management
- Audit Readiness Programs & Internal Audits
- Business Analysis & Process Improvements
- Policy Development & Implementation
- Managed Care & Health Insurance Operations
- Research, Reporting, & Communications
- Leadership & Program Administration
- Team Building & Staff Training & Development
- Member Enrollment & Claims Management
- Production, Metrics & Recommendations
- Evaluating, Investigating & Resolving Issues
- Client & Vendor Relationship Management
- Procedural Documentation Requirements
ADDITIONAL EXPERIENCE
- Quality Improvement/Compliance Analyst | Anthem, Inc.| Newbury Park, CA
- Project Administrator | Anthem, Inc.| Newbury Park, CA
- Health Plan Advisor| Anthem, Inc.|Newbury Park, CA
- Agent Broker Liaison II| Anthem, Inc.|Newbury Park, CA
Timeline
Grievance and Appeals Analyst
Anthem, Inc. (Elevance Health, Inc.)
09.2020 - Current
Financial Operations Specialist, External Sales Compensation
Anthem, Inc. (via BC Forward)
02.2020 - 12.2020
Performance Quality Analyst III, Sales Compensation, Licensing & Credentialing
Anthem, Inc.
10.2017 - 12.2019
Compliance Coordinator, Corporate Compliance
Clinicas Del Camino Real, Inc.
05.2016 - 01.2017
Compliance Audit Specialist, Medicare Compliance Sales & Marketing
Anthem, Inc.
09.2011 - 02.2015
Bachelor of Science - Organizational Leadership
California Lutheran University
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