Ernan Banez
Sr Quality Analyst Ii Appeals & Grievances Csc @L.A. Care Health Plan
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WORK HISTORY
Sr Quality Analyst Ii Appeals & Grievances Csc @L.A. Care Health Plan
Performs variety of audits within the appeals department, investigate, analyze and resolve member and provider complaints and appeals exercising strong independent judgment. Providing resolution of complaints in compliance with Centers for Medicare and Medicaid Services (CMS), California Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Managed Risk Medical Insurance Board (MBMIB) and National Committee for Quality Assurance (NCQA) regulatory requirements. Performs audit reviews pre-service authorizations, concurrent and post-service (retroactive review) medical necessity; benefit coverage appeals and reconsiderations, and complex provider claim disputes. Performed audits for tracking, trending and reporting complaints and appeals, as well as participating in internal and external oversight activities.Responsible for maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting noncompliance, adhering to company policy and procedures, including accreditation requirements, applicable federal, state and local laws and regulations.Performed audits that Identifies, investigates, and resolves administrative complaints, complex provider appeals and State Fair Hearing adhering to CMS, DHCS, DMHC, MRMIB and NCQA standards and regulations. Intakes, acknowledges, audit case files and resolves complaints for investigation and resolution, exercising strong independent judgment.Ensures integrity of A&G database by thorough, timely and accurate assignment of cases. Monitors closure of complaints and works with Quality Control Supervisor to resolve all database issues.Prepare audits and analyze monthly appeal and grievance reports to meet internal and external reporting requirements.Participates in internal and external oversight activities, inter-rater reliability reviews and focused audits.
EDUCATION
Cerritos College
Pharmacy
Cypress College
Radiologist Assistant
ABOUT ERNAN BANEZ
Over 20yrs experienced in Healthcare Industry. Skilled in Quality Authorization Claims & …
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