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Ben J. Joseph Objective: To pursue a challenging career in a field that utilizes my vast knowledge and experience in the Healthcare Industry.

Professional Experience:

Anthem Blue Cross of California Woodland Hills, California Appeals and Grievance Analyst April 4, 2016 to Current

• Resolved complex issues. Interpreted and explained health plan benefits, policies, and procedures to members and providers.

• Respond to and closes cases within appropriate regulatory requirements based upon type of case.

• Ability to Utilizes guidelines and review tools to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize and route to nursing and/or medical staff for review.

• Analyzes and renders determinations on assigned non-complex grievance and appeal issues and completion of the respective written communication documents to convey the determination.

Blue Shield of California Woodland Hills, California Senior Clinical Appeals and Grievance Coordinator June 12, 2006 to March 28, 2016

• Research and resolve complex and time sensitive member grievances, appeal and complaints of clinical and non-clinical nature.

• Interpret and explain health Plan benefits, policies, procedures to both members and providers while maintaining objectivity and professional demeanor.

• Research and process standard and expedited appeals, as well as Potential Quality Issues (PQI), for all commercial Blue Shield of California (Blue Shield) and Blue Shield Life and Health (Blue Shield Life) lines of business.

• Research cases to present and provide written synopses to clinical staff including Registered Nurses and Medical Directors.

• Respond to and closes cases within appropriate regulatory requirements based upon type of case

• Strategize, develop, present and implement revised workflows to various areas to drive efficiency within the department.

• Establish and maintain excellent working relationships with staff and management, as well as internal and external customers.

Blue Cross of California (Well point/Anthem) Woodland Hills, California Senior Appeals and Grievance Coordinator June 2005 to June 2006

• Resolved complex issues. Interpreted and explained health plan benefits, policies, and procedures to members and providers.

• Met or exceeded established quality and productivity standards in all areas of grievances, appeals and complaints.

• Assisted Manager and Director with escalated appeal issues. Worked closely with internal and external customers, including; Medical Directors, Medical Groups, Physicians and Pharmacies to assure that member concerns were addressed.

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Blue Cross of California (Well point/Anthem) Woodland Hills, California Customer Service Associate Level I, Level II and Level III June 2002 to June 2005

• Completed required training including claim pricing in order to accurately and effectively handle member calls.

• Developed new workflows to create an efficient workplace. • Collaborated across teams to share information and coordinate new ideas, to promote

enhanced customer service. • Cross trained on a variety of products and services, to meet customer needs effectively and

efficiently.

Skills

• Established and maintained excellent relationships with co-workers and management, including Medical Groups, Physician offices and Department of Managed Health Care (DMHC).

• Knowledge of HMO, PPO and POS Appeals and Grievance policy and procedures mandated by Department of Managed Health care (DMHC)

• Excellent Customer Service Skills • Excellent analytical, organizational and decision-making skills • Excellent interpersonal, written and verbal communication skills

Summary of Attributes:

• Highly motivated and detail oriented professional with over 11 years of healthcare experience. • Extensive knowledge of HMO, PPO, POS and RMC/ASO plans. • Strong time management skills with the ability to work under strict deadlines set by regulatory

agencies (Department of Managed Health Care, CA Department of Insurance) and the National Committee for Quality Assurance.

• Detail oriented with solid organizational skills to meet the demands of a fast paced work environment.

• Excellent communication skills. • Knowledge of CPT, ICD-9, ICD-10 coding as well as claims payment methodology.

Accomplishments

• Developed and implemented specific group strategies to become more efficient. • Actively participated with leadership in the betterment of the team. • Ability to quickly learn company policies, contracts, benefits, and put into practice which

afforded the team the higher possibility of success. • Pride in my ability to work independently and accomplish tasks.

Programming and Software Skills

• Microsoft Office XP • Entourage • Outlook Express • Microsoft Windows® 2000 • Apple Macintosh Platform

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Education

• Theological Studies- First Assembly of God, North Hollywood, CA ▪ 1997- Present • High School Diploma – Cleveland High School, Northridge, CA ▪ 1993-1997 • AAPC- Medical Coding CPC, Inglewood, CA July 2016-Present

References

• Personal and Professional reference upon request