Appeal And Grievance Coordinator resume example with 11+ years of experience
JessicaClaire
, , 609 Johnson Ave., 49204, Tulsa, OK100 Montgomery St. 10th Floor
H: (555) 432-1000
C:
resumesample@example.com
Date of Birth:
India:
:
single:
Summary
Highly motivated, well rounded in most aspects of healthcare, professional. Detailed-oriented with significant background in working closely with customers, members and professionals to identify issues, to resolve problems, to improve customer satisfaction levels, and build lasting relationships.
Skills
Highly organized, detail oriented and self-directed with the ability to work independently and in team setting
Windows, Word, and Excel based operating system;
Type 45 WPM
Broad understanding of medications and pharmaceutical terminology
Detailed knowledge of and ability to research and look up various codes. Service diagnosis codes ICD-10, procedure codes, CPT, revenue, HCPC
Ability to work in a fast-paced environment and manage time sensitive task completion daily
Ability to interact effectively and professionally with all levels of management as well as internal/external vendors and members
Ability to synthesize and process complex information and deliver the information both verbally and in writing in a clear, concise and articulate manner
Strong organizational, analytical and problem-solving skills
Highly organized, detail oriented and self-directed with the ability to work independently and in team setting
Analytical ability with an affinity to detail, as well as the capability to handle heavy workloads and meet deadlines
Flexible and willing to perform all necessary and appropriate duties to ensure the attainment of departmental and organizational goals
Experience
Appeal and Grievance Coordinator, 07/2021 - Current Montage Hotels – Fort Lauderdale, FL,
Investigate grievances and appeals
Respond to complaints, grievances and appeals in a consistent fashion, adhering all regulatory, accreditation and internal processing timelines and guidelines
Gather member information, claims, benefits, call histories,
Using different sites, Magellan/RAD md, New Century Health, AIM, JIVA, MAAGC, Inspire, Siebel, Diamond, Customer Connect, Provider connects, EIP
Interact with other department including Member services, Claims, Provider relations, and Utilization Management to resolve member and provider to resolve the grievances and appeals
Develop strong communication and business relationships with other departments, external vendors, and providers. examples: Care Centrix, New Century Health, Prime Therapeutics
Demonstrated self-reliance by meeting and exceeding workflow needs.
Multitask projects and tasks to ensure high quality and timely delivery.
Documented all information correctly for Medicare audits
Synthesize and process complex information and deliver the information both verbally and in writing in a clear, concise and articulate manner
Help encourage growth of fellow co workers, in training and guidance
Complete all tasks within the compliance guidelines and times for Medicare
Keep cases in compliance with Medicare
able to grow from feedback provided
Universal Medicare Service Advocate IV, 06/2020 - 07/2021 Harris Teeter, Llc – Kill Devil Hills, NC,
Handle incoming calls from Members
Document Customers Calls
Investigate Claims
Send Claims for reprocessing
Document Grievances and Appeals
Provide members with their Benefits for the plan enrolled in
Gather Information to solve the billing issues
Call Physicians, Hospitals, and Billing offices to get billing issues settled
Coordinate with other companies to provide services members
Knowledge of Medicare Advantage and Supplement Plans
Use Multiple systems to resolve members complaints
Use Diamond, Siebel, Sapphire, Customer Connect, Claims repository
Use Enterprise Image Processing, Inspire, Knowledge 360
Finesse, Skype, Microsoft teams
Knowledge of Cpt codes, Icd 10 codes, billing codes
Medicare time guidelines for appeals and Grievances
Built customer loyalty and strength by finding solutions to customers needs.
Receives and responds to inquiries from all communication venues
Documenting charts, and all information
Processing Medicare Prior authorizations
Answering phones and answering questions
Using multiple computer programs
Call center
Outreach to providers for information
Documenting all calls and outcomes
Verified details with policyholders and requested additional information.
Verified policy holder data, including age, contact number and physical address.
Complied with confidentiality regulations in handling customer information.
Retained strong medical terminology understanding in effort to better comprehend procedures.
Massage Therapist, 07/2016 - 11/2019 Montage Hotels – Pendry Park City, UT,
40 hours plus weekly
Provide therapy to patients
Massage
Exercises
Rehab
Electrical Stimulation
Ultrasound
Document the Patient’s chart
Assist with billing
Performed quality, therapeutic bodywork to meet clients' needs.
Protected workplace culture by building relationships with team members, respecting diversity and supporting goals.
Safeguarded client experience, maintaining confidentiality and upholding commitment to safety.
Gave clients individualized suggestions for stretching, strengthening, postural and relaxation techniques.
Formulated targeted massage plans based on individuals' physical condition, histories and current concerns.
Assisted patients with injury recovery as part of comprehensive physical therapy plans involving massaging affected muscles to improve mobility and reduce pain.
Assisted with basic bookkeeping, filing and maintaining clients' records.
Maintained clean, safe and well-organized work environment.
Maintained patient records, tracking rehabilitation goals and progress
Addressed injuries, trauma and stress using myofascial release.
Instructed patients in proper use of therapeutic exercise techniques and devices.
Coordinated with doctors and chiropractors to execute physical therapy treatment plans.
Guided clients through PNF stretches to target nerve receptors and extent muscle length.
Utilized cross-fiber friction techniques to facilitate strong, flexible repair in site-specific muscle and connective tissue injuries.
Applied pressure to specific body points to relieve muscle tension and related symptoms.
Record and prepare medications for delivery to nursing homes
Receive returned medications and kits,
Collect the hard copies for Controls and packaging slips
Maintain a high degree of accuracy with picking and checking customer orders
Audit inventory information, stock status and inventory balances for accuracy, availability and reordering decisions
Perform inventory replenishments in the warehouse
Meet and exceed established metrics for daily productivity
Refurbish returned units to be used again by new customers
Create and attach ticket labels to shipping containers
Unload, examine and verify incoming shipments; correspond with carrier to rectify damages and shortages
Become proficient with company’s inventory management software
Maintain daily interaction with other departments in the company when necessary
Perform on-call duty occasionally in order to satisfy emergency needs
Maintain cleanliness of work areas
Performs other duties as assigned
Compounding creams and lotions
Pharmacy Technician, 01/2014 - 11/2015 Flagler Hospital – City, STATE,
40 hours plus weekly
Fill Pyxis Machines
Load and unload Pyxis
Repackage bulk medicines
Pull needed medicines from Talyst
Restock Taylst
Deliver medicine to departments
Refill crash carts and emergency boxes
Create compounds when needed
Compounds IVs, TPNs
Compounds Chemo medications
Manage overall inventory
Assist Pharmacist as needed
Teamed with peers, technicians and pharmacists to prioritize and complete orders.
Assisted pharmacist with clearing high volume of prescriptions and responded to customer questions.
Inspected medication storage locations to monitor drug expiration dates and supply adequate inventory.
Received and verified daily incoming drug inventories, reported discrepancies and logged items into inventory system.
Prepared prescription transfers to other pharmacies.
Flagged potential side effects and allergies to prescribed medications for patients.
Verified prescriptions and drug labels, documents and packages.
Maintained strict patient confidentiality to adhere to HIPAA regulations and avoid data compromises.
Maintained clean and organized pharmacy shelving and work areas.
Managed inventories, rotated stock, removed expired or damaged drug products and resolved discrepancies in drug counts.
Performed wide range of pharmacy operations with strong commitment to accuracy, efficiency and service quality.
Prepared prescription labels, promoting accuracy in medication administration and dosing.
Massage Therapist, 05/2011 - 06/2015 Bamboo Gardens Salon – City, STATE,
Assess clients' soft tissue condition, joint quality and function, muscle strength, and range of motion
Refer clients to other types of therapists when necessary
Treat clients in professional settings or travel to clients' offices and homes
Develop and propose client treatment plans that specify which types of massage are to be used
Confer with clients about their medical histories and problems with stress or pain to determine how massage will be most helpful
Provide clients with guidance and information about techniques for postural improvement and stretching, strengthening, relaxation, and rehabilitative exercises
Massage and knead muscles and soft tissues of the body to provide treatment for medical conditions, injuries, or wellness maintenance
Prepare and blend oils and apply the blends to clients' skin
Apply finger and hand pressure to specific points of the body.
Pharmacy Technician, 10/2013 - 01/2014 Guardian Pharmacy – City, STATE,
40 hours plus weekly
Fill prescriptions,
Repackage bulk medicine
Create compounds
Reorder stock
Prepare IV medicine in under the IV hood
Aseptic techniques
Education and Training
Bachelor of Applied Science: , Expected in 05/2019 - Siena Heights University - Adrian, MI GPA:
Certificate: Pharmacy, Expected in 10/2013 - Everest University - Jacksonville, FL, GPA:
Certificate: Massage Therapy, Expected in 10/2009 - Keiser Career College - Jacksonville, FL, GPA:
Certifications
National Certification Board for Therapeutic Massage and Bodywork (NCBTMB)
Certified by the Pharmacy Technician Certification Board (PTCB)
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