Appeal And Grievance Coordinator resume example with 11+ years of experience

Jessica Claire
  • , , 609 Johnson Ave., 49204, Tulsa, OK 100 Montgomery St. 10th Floor
  • H: (555) 432-1000
  • C:
  • Date of Birth:
  • India:
  • :
  • single:

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.

  • 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

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.
  • Prepared solutions to ensure customer retention.
Senior Appeals Coordinator, 11/2019 - 03/2020
Harris Teeter, Llc Potomac, MD,
  • 40 hours plus weekly
  • Process Prior Authorizations
  • Document prescription request
  • Gather information needed for appeals
  • 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.
Pharmacy Technician, 11/2015 - 07/2016
Harris Teeter, Llc Reston, VA,
  • 40 hours plus weekly
  • Compound IV’s
  • TPN
  • 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
Certificate: Pharmacy, Expected in 10/2013
Everest University - Jacksonville, FL,
Certificate: Massage Therapy, Expected in 10/2009
Keiser Career College - Jacksonville, FL,
  • National Certification Board for Therapeutic Massage and Bodywork (NCBTMB)
  • Certified by the Pharmacy Technician Certification Board (PTCB)

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Resume Overview

School Attended

  • Siena Heights University
  • Everest University
  • Keiser Career College

Job Titles Held:

  • Appeal and Grievance Coordinator
  • Universal Medicare Service Advocate IV
  • Senior Appeals Coordinator
  • Massage Therapist
  • Pharmacy Technician
  • Pharmacy Technician
  • Massage Therapist
  • Pharmacy Technician


  • Bachelor of Applied Science
  • Certificate
  • Certificate

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