David Rodriguez

I’m looking for a challenging role to learn and enhance my career. 
 

Skills:

Management/Customer Service/Microsoft Word/Microsoft Excel/ Microsoft Power Point/QuickBooks/Inventory Control/Merchandising/Sales/Microsoft Office/Salesforce/KPI/Call Center/Personal Skills/Attention to Detail.

EmblemHealth (August 2015-January 2024)

            Supervisor Grievance and Appeal 

• Leader of the following team processes: Clinical Appeals, Independent Dispute Resolution Agency Appeals, Independent Review Organization Appeals, Dispute Resolution Agent Appeals, Commercial Dental Appeals, Clinical Dental Appeals, GHI PPO Commercial Grievances and Complaints, Medicare Grievance/Complaints/Part D appeals, and Senior Medical Clerks. 
• Ensured compliance is maintained with all aspects of NCQA, URAC, and CMS guidelines. 
• Interviewed and trained new hires on all health insurance policies. 
• Conducted audits, prepared cases for audit, and took part in CMS/NCQA/Regulatory audits. 
• Audit staff’s files via the Quality Assurance process, processed high level cases for Office of Personal Management (OPM) Federal cases. Handled escalated/irate member and provider phone calls.
• My team consist of 12 specialist that report to me.
• Interictal part of sprint system testing and training.   
• Responsible for updating the departmental contact list for external and internal contacts.
• Provide regular coaching and training to Specialists to ensure success in their role and also prepare them for growth & development opportunities
• Build & maintain healthy relationships with other departments to facilitate timely grievance processing.
• Identify and elevate grievance trends with a focus on problem solving using critical thinking.
• Updated KPI reports in addition to issuing corrective action plans (CAP) to reduce errors with a strong focus on accountability. 
• Assisted with queue based inventory in a high inventory environment by assigning out cases to specialist at times.
• Implemented new processes and enhanced existing processes to be more efficient. 
• Partnered with external agencies such as IMEDECS, MCMC, KEPRO, HQSI, and ESMEF to ensure continuity with our processes.
• Coordinated with delegated entities such as HealthCare Partners, eviCore, Ortho-Net, Montefiore, etc… to ensure the integrity of appropriate responses for our cases. 
• Prepared and reviewed MFSI packets prior to being sent off for integrity.

EmblemHealth (September 2008-August 2015)

Quality Assurance Specialist

• Oversee the department’s quality initiatives along with assisting in the development,

implementation and maintenance of the department’s quality assurance program. 

• Provided standardized reports, performed quality audits and file reviews in a professional and confidential manner that adhered to NCQA regulations, state, and federal guidelines. 
• Consistent development, retention and application of HIP benefits, contracts and departmental procedures.
• Trained and re-trained staff.
• Daily logs of files audited were accurately maintained and reports were written which included

recommendations for improvement. 

• Subject Matter Expert in Grievance and Appeal related matters for the company, composing procedural documents in our internal repository.

EmblemHealth (July 2007 – September 2008)

Grievance & Appeal Analyst

• The primary purpose of this job was to respond to written and/or verbal grievances, complaints,

and appeals submitted by members and providers in accordance with the regulations by NCQA,

CMS, NY State and other entities. 

• Provide written acknowledgment of all members and provider.

correspondence. Conduct thorough investigations of all member and provider correspondence by

analyzing all the issues involved and obtaining responses and information from internal and

external entities. 

• Interface with HIP’s departments, Delegated Entities, Medical Groups, and

Network Physicians to ensure resolution of case issues. 

• Compose all types of correspondence related to processing their cases. Prepare written responses to all member and provider correspondence. 
• Monitor daily and weekly pending reports and personal work list as well as make

necessary follow up calls to internal and external entities to ensure that cases are completed on or

before the applicable timeframe. Note all actions taken in the investigation for auditing and

reporting purposes. Prepare case narratives, which included the chronology of events for all

completed files.

EmblemHealth (May 2006 – July 2007)

Customer Service Representative

• Facilitating customer inquiries from members and providers regarding professional and facility claims, claims basics, basics of health insurance, HMO benefit basics, EPO/PPO/POS benefit basics, prior approval, Medicare benefit basics, Medicare Part D, Medicaid benefit basics, Pharmacy benefit basics, claims coding basics, medical terminology, in a customer service call center environment.
• Maintained a detailed knowledge of basic products, services, policies, procedures, maintenance and regulatory requirements. Able to handle a diverse array of complex customer situations with minimal supervisory assistance by making sound decisions that minimize risk to client and customer.
• Actively listened to determine full extent of customer's needs while appropriately applying different approaches to affect desired outcome.
• Ensured effective customer communication by utilizing superior verbal and written skills.
• Handled basic customer complaints and problems with minimal assistance. Able to recognize personal limitations in an acceptable time frame and initiate requests for assistance to appropriate personnel as needed.

CVS Pharmacy (July 2004 - February 2006)

                 Shift Supervisor

• Executed managerial duties such as assigning employee tasks, handling of deposits, opening and closing the store.
• Training of new employees, boosting employee and customer moral, inventory control, payroll, maintaining employee schedules, implementing new displays for new products, maintaining the implementation of new products monthly, product withdrawals, and customer service.
• Loss prevention duties.
• Deescalating irate Customers via phone and in person.
• Responsible for Customer Returns.

St. John’s University (September 2000 – 2002)

Major: Business Management 

St. Raymond’s High School for Boys (1996-2000)