Antonio R. Canlas Jr.
Los Angeles
Summary
To gain experience with a company where I can actively contribute to continuous improvement.
Overview
24
24
years of professional experience
Work History
Grievances and Appeals Auditor
Elevance (Anthem Blue Cross)
10.2022 - 06.2025
- Reviews cases to determine applicability of, and compliance with, federal and state regulations, enterprise policies and procedures and all related accreditation standards.
- Reviews cases to assess whether it was appropriately handled as a clinical or administrative request and was correctly processed to avoid prompt pay penalties.
- Evaluates urgency of clinical situations to assess appropriate handling, determine if sufficient records were obtained, and review medical records and medical policies to determine if correct criterion has been utilized in each review.
- Reviews case documentation to assess appropriate system entries have been made and that the step-by-step process is sufficient to mitigate risk associated with regulatory reviews, accreditation reviews, and potential litigation.
- Assists management in process improvement strategies to achieve business objectives.
- Identifies and communicates error trends to improve overall quality of enterprise G&A team.
Grievances and Appeals Analyst
Elevance (Anthem Blue Cross)
02.2010 - 10.2022
- Responsible for reviewing, analyzing and processing policies related to medical and pharmacy claim events to determine the extent of the company's liability and entitlement.
- Conducted investigation and review of customer grievances and appeals involving provision of service and benefit coverage issues for medical and pharmacy benefits.
- Contact customers to gather information and communicate disposition of case, documents interactions.
- Generated written correspondence to customers such as members, providers and regulatory agencies.
- Researched administrative or non-clinical aspects of the appeal, e.g. eligibility, benefit levels, overall adherence to policies and practices.
- Made decisions on appeals where guidelines are well documented and involve limited discretion.
- Prepared files for internal or external review by analysts, medical staff or outside consultants.
- Triaged clinical and non-clinical inquiries, grievances and appeals, prepares case files for member grievance committees/hearings.
- Summarized and presented essential information for the clinical specialist or medical director and legal counsel.
- Interpreted policy and benefit information from member and provider contracts.
Customer Service Representative
Elevance (Anthem Blue Cross)
12.2001 - 02.2010
- Respond to inquiries from members, providers, or brokers via phone, email, or written correspondence concerning insurance benefits, eligibility, provider contracts, claims, and billing issues.
- Analyze problems, research information, and provide accurate, helpful solutions in a timely manner.
- Develop and maintain positive relationships by coordinating with internal teams (e.g., claims, providers, care management) to ensure seamless service delivery.
- Handle follow-ups complex policy interpretation, claims issues, and escalations, return calls or emails, and ensure resolution of routine or complex inquiries.
Education
High School -
St. Mary Magdalene High School
01.1996
Skills
- Customer Service
- Analytics
- Problem solving
- Research
- Communications
- Bilingual Tagalog (Filipino)
Timeline
Grievances and Appeals Auditor
Elevance (Anthem Blue Cross)
10.2022 - 06.2025
Grievances and Appeals Analyst
Elevance (Anthem Blue Cross)
02.2010 - 10.2022
Customer Service Representative
Elevance (Anthem Blue Cross)
12.2001 - 02.2010
High School -
St. Mary Magdalene High School