LOVEYNA CHAN
Long Beach
Summary
Eager to contribute to team success through hard work, attention to detail, and excellent organizational skills. Recognized consistently for performance excellence and well-known for resolving issues effectively. Motivated to learn, grow, and excel in any professional industry.
Overview
18
18
years of professional experience
Work History
Pharmacy Rep
Molina HealthCare
02.2024 - Current
- Handles and records inbound pharmacy calls from members, providers, and pharmacies to meet departmental, State regulations, NCQA guidelines, and CMS standards
- Provides coordination and processing of pharmacy prior authorization requests and/or appeals
- Assists with clerical services/tasks and other day-to-day operations as delegated
- Effectively communicates plan benefit information, including but not limited to, formulary information, copay amounts, pharmacy location services and prior authorization outcomes
- Assists member and providers with initiating oral and written coverage determinations and appeals
- Records calls accurately in call tracking system in Salesforce.
Lead Cashier
AIM Sports Group
11.2023 - Current
- Maintained a balanced cash drawer with diligent attention to detail and accurate counting practices.
- Trained, mentored, and developed new cashiers with positive and encouraging techniques to maximize performance and team contributions.
- Assisted customers by answering questions and fulfilling requests.
- Processed both cash and card purchases and returns.
- Coordinated breaks for fellow cashiers to ensure continuous coverage at all times while minimizing downtime.
- Performed store opening, closing, and shift-change actions and kept accurate shift-change logs.
- Maintained stock to meet expected customer demand.
Guest Service Representative
ASEC/ UCLA Health Training Center
09.2023 - Current
- Welcomed guests on arrival, displaying professional and friendly approach.
- Responded to guest inquiries, complaints and special requests to increase customer satisfaction.
- Assist guests with ticket reservation, resolving any issues promptly and professionally.
- Scan event tickets for validity.
- Assist guest with assigned seating.
- Ensure safety for all guest and facility
Claims Examiner II
ALTAMED (ALTURA MSO)
06.2023 - 02.2024
- Ensure compliance with regulatory standards, company policy and guidelines
- Interpret DOFR and contracts to unsure accurate payment
- Process professional claims for payment according to contract, LOA, Medi-Cal fee for service schedule, or Medicare rates in Share system
- Verifies member eligibility, benefits, Proof of timely for claim submission, and authorizations and forms as needed
- Verifies provider and vendor name and address and other data
- Identify and triage disputes to appropriate departments
- Submit authorization requests to Utilization Management Department
- Correct any feedback given by Quality Auditors
- Maintains the accuracy level required for this position
- Performs other duties and assigned by management.
- Handled sensitive information with discretion, ensuring confidentiality of personal and financial details for claimants throughout the claims examination process.
- Utilized analytical skills to evaluate medical bills for accuracy and appropriateness of charges before approving payments as part of the claims process.
Provider Disputes Specialist
BLUESHIELD OF CALIFORNIA
05.2020 - 06.2023
- Generates and mails patient/provider and/or IPA letters as needed
- Forwards mail as needed to other departments of Care1st
- Interpret DOFR and contracts to review appeals to process or uphold
- Process claims for payment according to contract, LOA, Medi-Cal fee for service schedule, or Medicare rates in Facets system
- Verifies member eligibility, benefits, Proof of timely for claim submission and appeal, and authorizations and forms as needed
- Verifies provider and vendor name and address and other data
- Analyzed, researched and resolved payment claims within required timeframes.
- Conducted root cause analysis on recurring disputes to identify opportunities for prevention or mitigation of future occurrences.
- Resolved disputes efficiently by conducting thorough investigations and applying appropriate resolution strategies.
- Identify and triage disputes to appropriate departments such as the Recovery, Claims, and Optum department
- Submit authorization requests to Nurses and MDs
- Correct any feedback given by Quality Auditors
- Maintains the accuracy level required for this position
- Performs other duties and assigned by management.
Sr Quality Claim Analyst
UNITED HEALTHCARE
03.2016 - 05.2019
- Analyze and identify trends and provide feedback and reports to reduce errors and improve claims processes and performance, then those reports are taken back to team members to provide feedback on the audit results
- Create, maintain, and track reports in relation to performance of an individual and or as a corporate
- Research, approved/denied claims, and grievances thoroughly by reviewing medical records, medical director notes, and health plan guidelines
- Knowledge of end-to-end business processes from quality of work to team management.
- Collaborated with cross-functional teams to identify opportunities for process improvement and increased efficiency.
- Validated results and performed quality assurance to assess accuracy of data.
Senior Appeals Coordinator
UNITED HEALTHCARE
12.2012 - 03.2016
- Communicate with appropriate parties regarding the outcome of the appeal issues via phone/email
- Reviewed and verified data, including addresses, phone numbers, names, ages, and values
- Checked documentation for accuracy and validity on updated systems
- Received and routed business correspondence to correct departments and staff members
- Devoted special emphasis to punctuality and worked to maintain outstanding attendance record, consistently arriving to work ready to start immediately.
- Managed high caseloads effectively while maintaining strict deadlines for case resolution milestones.
Service Cashier/ Receptionist/ File Clerk
TOYOTA
06.2006 - 05.2009
- Process transaction, manage invoices, and direct multiple calls to appropriate parties
- Assisted managers in locating and organizing invoice numerically and alphabetically
- Verified customers’ services and payments
- Solved customer problems in-person or over telephone by aiding with resolving a balance due, directing to a sales team member, and transferring calls to different departments.
- Enhanced store productivity by maintaining a clean and organized cashier area.
- Handled customer inquiries, resolving issues promptly for increased satisfaction.
- Liaised between service manager and service team by greeting customers and answering calls to promote smooth transition of service functions.
- Assisted in training new cashiers, leading to improved performance across the entire team.
- Completed end-of-day closing procedures thoroughly and efficiently, preparing the register for the next business day''s opening staff member.
Education
Pharmacy Technician License - Pharmacy Technology
American Career College
Los Angeles, CA08.2009
High School Diploma - General Studies
Polytechnic High School
Long Beach, CA06.2005
Skills
- Perseverance and Motivation
- Claims investigation and research
- Patient-focused quality service
- Claims reports and documentation
- Process Improvement
- Adaptable Team Player
- Quality review processes
- High-quality customer service
- Detail Oriented
- Pharmaceutical knowledge
- Problem-solving skills
- Answering customer questions
- Confidentiality and HIPAA
References
Available Upon Request
Timeline
Pharmacy Rep
Molina HealthCare
02.2024 - Current
Lead Cashier
AIM Sports Group
11.2023 - Current
Guest Service Representative
ASEC/ UCLA Health Training Center
09.2023 - Current
Claims Examiner II
ALTAMED (ALTURA MSO)
06.2023 - 02.2024
Provider Disputes Specialist
BLUESHIELD OF CALIFORNIA
05.2020 - 06.2023
Sr Quality Claim Analyst
UNITED HEALTHCARE
03.2016 - 05.2019
Senior Appeals Coordinator
UNITED HEALTHCARE
12.2012 - 03.2016
Service Cashier/ Receptionist/ File Clerk
TOYOTA
06.2006 - 05.2009
Pharmacy Technician License - Pharmacy Technology
American Career College
High School Diploma - General Studies
Polytechnic High School
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