Lillian V.
Healthcare Professional
- Role
- Appeals and Grievance Specialist Ii at L.A. Care Health Plan
- Location
- San Diego, CA, US
- LinkedIn followers
- 500 followers
About Lillian V.
As a dedicated healthcare professional, I bring a diverse range of skills in health insurance leadership, customer service, and administrative management. My experience spans across key areas including Appeals and Grievances (A&G), member and provider disputes, Claims, Utilization Management, Authorizations, Accounting/Billing, Coordination of Benefits, Specialty Medications, Behavioral Health, and Managed Care.Throughout my career, I have been committed to supporting both patients and providers with claims analysis, A&G support, provider dispute resolution, HIPAA Compliance, and general healthcare coordination. I have also managed and supervised teams of 12-26 representatives, overseeing daily operations to ensure high-quality service delivery. My expertise includes reviewing and analyzing complex documents for accurate non-clinical determinations, managing peer-to-peer review scheduling, conducting contract management, and ensuring compliance across various healthcare plans.With a strong understanding of medical terminology, including ICD-9/ICD-10 and HCPCS codes, I am proficient in navigating various healthcare platforms and systems to streamline operations. I am well-versed in handling diverse healthcare plans, including Tricare, PPACA/Marketplace (ACA plans), Commercial plans, CalPERS, Medi-Cal (Medicaid), Medicare, Policy procedures, contracts, contract addendums, Explanation of benefits, and coverage, plans ranging from HMO, PPO, HSA, POS, and EPO\'s. Additionally, I have extensive experience in managing office operations, from hiring and training new employees to overseeing accounts payable/receivable, conducting quality assurance, and ensuring thorough background checks and compliance with provider contracts.I am passionate about delivering high-quality service and am currently seeking a direct hire opportunity to continue contributing to the healthcare industry. Thank you for visiting my profile, and I look forward to connecting!
Experience
Appeals and Grievance Specialist Ii
Jun 2025 — Present
Education
Concorde Career Colleges
Medical Insurance Specialist/Medical Biller | Medical Management and Administration
University of Phoenix
Business Management
2026
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