| | | 20,000+ Fresh Resumes Monthly | |
|
|
| |
Click here or scroll down to respond to this candidateCandidate's Name
EMAIL AVAILABLE PHONE NUMBER AVAILABLE Fairburn, GASUMMARY Seasoned professional with years of experience in member relations and grievance coordination, currently serving as Appeals & Grievance Coordinator at Centene. Expertise in analyzing and resolving member and provider appeals, maintaining compliance with state and federal regulations, and enhancing customer satisfaction through effective issue resolution. Seeking to leverage extensive background in healthcare member advocacy and appeal processes in a new Appeals & Grievance Coordinator role. WORK EXPERIENCE CenteneAppeals & Grievance Coordinator II Jun 2023 - Present Investigate and resolve complex member inquiries, ensuring a seamless member experience from initiation to conclusion. Manage CRM activities, including the timely resolution of Healthcare Insurance Marketplace issues in compliance with CMS mandates. Collaborate with cross-functional teams and external stakeholders to address and document member complaints, improving overall service quality. Analyze member feedback and escalation data to propose actionable workflow and policy enhancements, promoting continuous improvement. Appeal & Grievance Coordinator I Jul 2022 - Jun 2023 Provide consultation for problem resolution for appeals staff and monitor team work output to ensure compliance with internal and NCQA standards Identify training, process improvement and resource needs to maximize team performance and recommend action plans to management Review denial and appeal letters as needed to ensure appropriate content and message Prepare for state/health plan audits, response to complaints and request for state fair hearing documentation Prepare monthly reports, logs, and other health plan or state contractual requirements Review and monitor team workload and output to ensure optimum efficiency and accuracy Serve as the point of contact for issues that arise from members, providers and internal team Train and educate new and existing team on processes, policies and procedures, and contract or market requirementsMember Advocate I Aug 2017 - Jul 2022 Resolved member complaints and grievances, ensuring timely adherence to procedural guidelines and identifying access issues for expedited resolution. Served as the primary liaison for advocacy groups, human service agencies, and state entities, enhancing member education on plan benefits and facilitating referrals to appropriate management programs. Coordinated compliance efforts, maintaining strict confidentiality in accordance with HIPAA regulations, and contributed to the successful execution of departmental projects. Delivered comprehensive training and support to staff, including the development of instructional materials and leading side-by-side coaching sessions, while managing dental escalations and contributing to talent acquisition processes. Review and release pended claims. Process member receipts. Assist in manual claim entry and member reimbursement. Complete claims adjustments. Meet quality and production standards.Customer Service Representative I Apr 2014 - Aug 2017 Addressed member and provider inquiries via telephone and written communication, ensuring responses adhered to established timeframe protocols and resource guidelines. Documented all interactions comprehensively for quality assurance and performance metrics within the CRM system, maintaining adherence to call center standards and turnaround times. Conducted thorough research to uncover processing errors in claim payments, coordinating with site operations for necessary adjustments, and contributed to policy and process enhancements by identifying call pattern trends to enhance customer service and efficiency.HP Enterprise ServicesContact Center Representative/Provider Relations Field Inspector 2012 - 2014 Resolved billing discrepancies by assisting providers with claim adjustments, ensuring accurate reimbursement processes. Conducted comprehensive site reviews to verify provider facility compliance, serving as a pivotal contact for provider relations and health plan coordination. RSA MedicalMedical Records/Administrative Representative 2008 - 2011 Verified patient medical records and facilitated payment processes, ensuring accuracy and compliance with financial protocols. Managed the release of information to authorized entities, adhering strictly to HIPAA regulations for confidentiality and security. Conducted training for new representatives and maintained meticulous transaction records within a call tracking system to support customer service operations. United Health GroupCustomer Service Representative 2007 - 2008 Provided effective resolution to customer inquiries regarding benefits, eligibility, and service requests, enhancing member satisfaction and engagement. Maintained optimal productivity by swiftly handling provider and member calls with a focus on quality service, minimizing idle time.AT&TGovernment Account Executive 2006 - 2007 Managed and expanded strategic relationships with key government agencies, delivering customized telecommunications solutions that resulted in a 15% increase in contract renewals for AT&T.All State InsuranceCustomer Care Representative 2005 - 2007 Skillfully managed inbound calls at All State Insurance, providing exceptional customer service by addressing inquiries, resolving issues, and effectively communicating policy details to enhance customer satisfaction and loyalty. ComcastCustomer Account Executive 2004 - 2005 Managed and resolved customer inquiries, ensuring high satisfaction by providing comprehensive account support, including billing issues, service requests, and technical troubleshooting, for Comcast's diverse client base. EDUCATION Northwestern Business CollegeBusiness Administration, Some Coursework Completed Colorado Technical UniversityBachelor of Science in Business Administration- Human Resource Management2022SKILLS Ability to Handle Multiple Activities Strategic Mentality to Identify Positive Opportunities Effective Interpersonal and Analytical Skills Ability to Delegate Tasks and Responsibilities Works Independently Prioritizes Project Steps, Milestones, and Time Requirements to Complete Projects Efficient Knowledge of Microsoft Office(Word, Excel, PowerPoint, Outlook) and Various Applicant Tracking Systems, ICD-9, CPT, HCPCs, Revenue Codes, Experience in HRIS Systems Skills: Analytical thinking conflict resolution data entry communication skills |
