Create and review CDAG (Medicare Coverage Determination) Compliance call reports and provide audit analysis to Customer Service Leadership, Training and Quality team to identify continuous improvement activities, compliance adherence and specialist performance within customer service Create, review and maintain FCR (First Call Resolution) Grievance report.
Conduct a thorough investigation of grievance report for complete and accurate grievance resolution, member satisfaction, categorization, and documented procedural adherence.
Determine operational impact and need action analysis; elevate immediate issues, report trends, and areas for improvement and opportunities to management through report analyst and maintenance.
Create and review compliance and operational data reporting and analysis along with managing ad hoc projects and other reports Document and communicate audit findings through written documents, models and quality huddle notes creation for grievance error specific trends.
Maintain, analyze and schedule departmental statistical reports and surveys in a timely manner to include recommendations for continuous process improvements initiatives as needed.
Assist in updating Grievance training materials along with Policy and Procedures for both Medicare and Commercial product lines for Customer Service and Appeals & Grievance Analyst.
Assist with external vendor management initiatives Created and reviewed financial reports; recouped several thousand dollars in lost revenue due to incorrect billing, death, and termination of benefits as well as processed reimbursement claims Grievance analyst Conduct investigations and root cause analyst to drive issue to the resolution of the member's grievance.
Accurately, completely and consistently, research and analyze member's issues and collected data in accordance with developed processes, policies and procedures and standards.
Review grievances sent to the member grievance workbasket and process via telephone or letter.
Provide thorough investigative skills to resolve complaints received directly from the Health Insurance Marketplace.
Review the electronic files that are sent from the Marketplace.
Processed and resolved state complaints, grievances, CTM complaints, LEP complaints, denials and appeals, email and social media complaints.
Participated in level 2 appeals telephone conferences and CMS audit.
Pharmacy analyst Lead technician on the implementation of PBM change and oversight.
Assisted with formulary updating, criteria formation, plan changes and minutes for P&T Committee Identified and reported FWA to the State of Michigan, resolved grievances and appeals from pharmacy and State of Michigan, Lead technician in medication drug review including high-dollar drugs, coordinated care of chemotherapy drugs with providers to maintain drug cost.
Assisted pharmacies in the proper billing of medications and supplies Assisted in Medicare enrollment, LEP determination, COB determination, and entry, created and reviewed reports, trained new employees, created training materials.
Accounts receivable liaison.
Assisted in guideline formation, formulary management including authorization criteria and medication pricing (AWP, FUL, WAC, MAC), network development, new program formation and testing.
skills and abilities High-Quality Auditor and Subject Matter Expert (SME) on multiple lines of businesses to include HMO/PPO/POS/ Federal Employee Health Plan and traditional health care delivery systems, benefits and riders, eligibility and Direct Pay programs and rates.
Analyst August 2016 to CurrentHAP
An Audit analyst who has worked in multiple positions to include Medicare Sales, Correspondence, and Grievances that create and review compliance reports, data analytics, trends, report maintenance and assist in policy and training updates.
Grievance analyst April 2016 to October 2016Blue Care Network
A grievance analyst who reviewed and completed Marketplace complaints (HICS) and participated in training new employees and grievance entry.
Pharmacy grievance analyst | Meridian rx June 2013 to October 2015
A pharmacy technician who processed grievances resolved escalated phone calls and prior authorization request.
Also participated in training new employees, troubleshooting liaison, phone queue and project management.
pharmacy analyst | total health care | april 2011 - march 2013.
A lead pharmacy analyst who participated in reporting, prior authorization review, CSHCS adherence, compliance reviewer, FWA auditor, overutilization reviewer, member and pharmacy locks, and revenue recoup analyst.
Bachelor of Science : Health Administration, 2019Eastern Michigan UniversityHealth Administration MACRAO & MTA transfer agreements
associate of science | may 2016 | henry ford college
pharmacy technician license
Certified Pharmacy Technician and fully licensed in the State of Michigan
An analyst seeking an opportunity to apply my vast knowledge and expertise in an environment where I can utilize my analytic skills efficiently and effectively while continuously learning and growing in the healthcare industry. Project Management skills through review and analyzing reports, addressing systematic issues with developers and IT to resolve, proposal writing, and policy updating. Leadership skills through organizing and conducting meetings, training, and teaching. Proficient in all Microsoft products to include Excel, Word, and OneNote Customer Service-driven through flexibility and by providing good judgment and logic Workforce management (WFM) background through call queue management Ability to work in any environment, strong problem-solving and investigating skills. Excellent written and verbal communication skills. Accounting background through finance classes and through purchase order creation and completion