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Click here or scroll down to respond to this candidatesorice46@gmail.Nello com Revere, Sorice MA PHONE NUMBER AVAILABLEWORK HISTORYAPPEALS AND GRIEVANCES PROVIDER CLAIMS COORDINATOR at Healthfirst Street Address /2022 - 06/2023 (1 year)* Responsible for data entry into MHS related to appeals process and outcome * Ensure appeals and grievances are categorized and processed within New York State and Federal timeframes.* Communicate with providers related to claims appeals and outcomes.* Responsibilities will include requesting waivers from providers for non- clinical Medicare claims appeals and submissions to MAXIMUS when waivers are not received.* Maintain absolute file integrity with regards to content, location and confidentiality.* Assist in analytical review of data to identify provider, member, and Healthfirst culpability for claims issues and provide feedback to management regarding trends * Function as liaison between A G, Provider Operations, and Network Management for provider claims issues.* Participate in Medicare Appeals Committee Meetings APPEALS AND GRIEVANCES REPRESENTATIVE at Boston Medical Center Health Net04/2022 - 06/2022 (3 months)Boston Medical Center Health Net Boston, MA * Executed member appeals across multiple departments within the Plan and with representatives from external vendors * Initiated, drafted and issued appeal results determination letters to members and external vendors * Communicated with members, providers and internal and external medical personnel to discuss appeal results when questions arose.GRIEVANCES AND APPEALS SPECIALIST at Papa12/2021 - 01/2022 (3 months)Papa Remote * Responsible for timely processing of grievances, complaints and all internal external * claim disputes in compliance with client SLAs * Advocated for member rights within the organization, assuring grievance and appeal trends were reported to and addressed within the appropriate quality improvement committee(s.) * Owned the end-to-end process of an escalation or complaint ensuring that a resolution was met the processes included documenting and sharing with stakeholders within defined requirements * Assured adherence to the customer-complaint, emergent non emergent case management referral process in accordance with company service level agreements * Identified action items required on each complaint and engage any appropriate department for follow up while overseeing each complaint to satisfactory resolution.* Conferred with managerial personnel to recommend changes to prevent recurring customer complaints * Prepared written documentation for follow- up or due diligence * Met compliance standards for complaints, including, but not limited to, monitoring the number of days open, facilitating adequate descriptions of complaints and their resolutions, and reviewing days to close * Thoroughly reviewed the monthly reports ensuring accuracy and thorough documentation in alignment with Papa Service Level Agreements * Other operational duties as assignedMEMBER APPEALS COORDINATOR at AllWays Health Partners, Neighborhood Health Plan05/2008 - 07/2021 (13 years)AllWays Health Partners, Neighborhood Health Plan Somerville, MA * Served as contact and liaison for MassHealth, Department of Insurance (DOI) and the Office of Patient Protection (OPP) * Thoroughly researched all appeals, gathered missing or required information, and prepared appeal cases for presentation to the Appeals Committee * Processed member appeals while adhering to specifically defined appeal policies for MassHealth and Commercial members * Assisted with Beacon Health Options appeals as requested by the AllWays Health Partners Manager of the Appeals and Grievances Department * Assisted Management and Compliance Department in preparing appeal cases for upcoming audits by NCQA(National Committee for Quality Assurance), URAC (Utilization Review Accreditation Commission) and KEPRO (Keystone Peer Review Organization)* Assisted in the notification to external agencies of appeal outcomes per MassHealth Board and OPP requirements * Responsible for timely written notification to members on the acknowledgement and resolution of an appeal * Stayed informed of changes related to AllWays Health Partners authorization and claims payment rules, benefit plans and new products * Identified internal systematic or procedural issues and reported them to Management, the Director of Quality * Control, Member Enrollment and any other appropriate department contacts for process improvement * Worked with various external vendors including CVS Caremark, MCMC and the Medical Review Institute of America (MRIoA) * Reprocessed claims and investigated member eligibility issues * Assisted Provider Appeals Coordinator with processing incoming provider appeals. SENIOR MEMBER APPEALS ANALYST at Tufts Health Plan Medicare Preferred 09/2003 - 05/2008 (5 years)Tufts Health Plan Medicare Preferred Watertown, MA * Received and performed initial research on member appeals and categorized each appeal appropriately * Led Member Appeals and Grievances staff including assisting department management when necessary * Acted as a resource to fellow analysts * Represented the department at interdepartmental meetings concerning company initiatives and projects and chaired and or contributed to interdepartmental meetings as needed * Identified time savers and process enhancements including development of workflows to put enhancements into place * Identified and handled escalated and or sensitive issues * Supported department initiatives and took on individual special assignments as needed * Corresponded with the member as required (Written acknowledgement, closure letters, telephone contact and documentation as appropriate) * Completed data entry and documentation requirements in MACESS and in department databases * Acted as a liaison and coordinated functions with internal departments relative to the status of a member appeal and the research needed to prepare the case for review * Presented cases to the Member Appeals Committee on a bi-weekly basis * Prepared cases for CMS external review and navigated the CMS website to determine Medicare benefit coverage criteria * Worked closely and interacted with department Managers, Clinical Specialists, Grievance Analysts, as well as the Clinical Case Managers and Medical Director on all expedited issues * Responsible for the timely processing of expedited appeals received and ensured all regulatory and department timelines were metAPPEALS AND GRIEVANCES ANALYST at Secure Horizons, Tufts Health Plan for Seniors05/2001 - 09/2003 (2 years)Secure Horizons, Tufts Health Plan for Seniors Watertown, MA * Received and performed initial research on member appeals * Categorized each appeal appropriately * Corresponded with the member as required (Written acknowledgement, closure letters, telephone contact, and documentation as appropriate) * Completed data entry and documentation requirements in MACESS and internal department databases * Acted as a liaison and coordinated functions with internal departments relative to the status of a member appeal and the research needed to prepare the case for review * Presented cases to the Member Appeals Committee on a bi-weekly basis * Ensured all regulatory and department timelines were met GIC MEMBER SPECIALIST at Tufts Health Plan06/1999 - 05/2001 (2 years)Tufts Health Plan Watertown, MA * Provided superior customer service by meeting the General Insurance Commission (GIC) account guidelines (30 second call answer time, 0 not ready time) * Adjusted and investigated member claims issues * Investigated GIC enrollment issues. MEMBER PROVIDER REPRESENTATIVE at Tufts Health Plan 11/1998 - 05/1999 (1 year)Tufts Health Plan Watertown, MA * Provided superior customer service to Tufts Health Plan members * Made necessary changes to member accounts(Address, phone number, date of birth and Primary Care Physician changes)* Issued new identification cards when necessary * Investigated enrollment issues.CLAIMS SPECIALIST at Notice Systems03/1998 - 10/1998 (1 year)Notice Systems Charlestown, MA * Provided superior customer service to First Notice System clients * Entered first notice of loss for various lines of business including workers compensation, commercial and personal liability, commercial and personal property, and commercial and personal auto insuranceEDUCATIONBunker Hill Community CollegeGraduated 1970Bachelor of Arts in Communication Liberal ArtsSKILLSSales, 14 yearsCustomer Service, 5 yearsLANGUAGESEnglish, BilingualSpanish, BilingualSOCIAL NETWORKSFacebook, https://ZeinebTwitter, https://YesLinkedin, http://LINKEDIN LINK AVAILABLE ABOUT MEI served in the militaryI have a drivers licenseI have management experience : 25 yearsI have a security clearance |
