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Appeals and Grievance Coordinator Resume Example

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APPEALS AND GRIEVANCE COORDINATOR
Summary

Goal driven, compassionate, and accountable professional with over 18 years of related, hands on experience in fast paced settings. Hard working and reliable with a full understanding of ICD-10-CM and CPT coding procedures. Excellent data entry skills allow for accurate coding of medical information, billing practice and provided care. Seeking a challenging key support role in health care administration where my several years of experience will contribute to the success of the organization.

Skills
  • Auditing
  • Billing
  • Contracts
  • Client
  • Customer Service
  • Database
  • Diagnosis
  • Documentation
  • Financial
  • Forms
  • Legal
  • Medical Billing
  • Meetings
  • Network
  • Organizing
  • Policy analysis
  • Policies
  • Quality
  • Quality improvement
  • Safety
  • Supervision
  • Problem resolution
  • Teambuilding

Experience
Appeals and Grievance CoordinatorCompany Name | City, State | Jan 2016-Current
  • Responsible and accountable for reviewing appeal and grievance ensuring compliance with company policies and contracts as well as State, Federal and Health Plan regulatory requirements for commercial lines of business.
  • Oversee and monitoring and review appeals and grievance concerns from members & provider.
  • Ensured that provider and member appeals were processed according to company health plans and policies.
  • Confirmed that all activities related to follow up functions meet department requirements, and levels of performance.
  • Provided analysis of the appeal and grievance.
  • Ensured compliance with regulations and controls by examining and analyzing records, reports, operating practices, and documentation; recommending opportunities to strengthen the internal control structure.
  • Interact daily with Customer Service Department, Medical Management Department, Medical Directors, Providers and Staff as necessary to effectively resolve appeals, complaints and quality of care or service issues.
  • Ensured that all legal, regulatory and policy requirements were met by keeping informed of changes and by implementing necessary controls and/or programs to meet requirements.
Senior Appeal RepCompany Name | City, State | Sep 2011-Jun 2015
  • Responsible and accountable for the supervision of claims auditing ensuring compliance with company policies and contracts as well as State, Federal and Health Plan regulatory requirements for commercial and senior lines of business.
  • Oversaw the monitoring and review of claim rep adjudication quality reports.
  • Ensured that provider and member appeals were processed according to company health plans and policies.
  • Confirmed that all activities related to follow up functions meet department requirements, maximized revenue collection, and achieved leading practice levels of performance.
  • Provided analysis of claim adjudication trends and identified training opportunities for claim reps.
  • Ensured compliance with regulations and controls by examining and analyzing records, reports, operating practices, and documentation; recommending opportunities to strengthen the internal control structure.
  • Demonstrated solid business, financial and program analysis capabilities including cost benefit analysis, cost effectiveness, economic and system evaluation skills.
  • Ensured that all legal, regulatory and policy requirements were met by keeping informed of changes and by implementing necessary controls and/or programs to meet requirements.
Senior Provider Service RepCompany Name | City, State | Mar 2009-Sep 2011
  • Responsible for supporting various provider service functions with an emphasis on working externally with plan's providers to educate, advocate and engage as valuable partners.
  • Served as resource expert regarding provider issues that may impact provider satisfaction.
  • Researched and resolved the most complex provider issues and appeals for prompt resolution.
  • Coordinated prompt claims resolution through direct contact with providers and claim department.
  • Researched, analyzed and recommended resolution or provider disputes as well as issues with billing and other practices.
  • Acted as a liaison to ensure the relationship between contracted entities and health plan is at an optimal level of service.
  • Coordinated and monitored performance and quality improvement capacity building for network physicians and regularly reported on the status of efforts and impacts.
  • Led department projects and initiatives; performed targeted outreach as related to project deliverables and collaborated with internal departments to resolve provider network issues.
  • Consistently met established productivity, schedule adherence and quality standards.
Reimbursement/WCI SpecialistCompany Name | City, State | Dec 2006-Nov 2008
  • Responsible for performing policy analysis for managed care issues by reviewing contracts, writing clause revisions, making recommendations for reimbursement policy changes, reviewing reports and financial data, and analyzing fee schedules, encounter forms, diagnosis, and procedure codes.
  • Ensured projects related to reimbursement issues were completed on time and changes were implemented appropriately by conducting meetings, organizing activities, reviewing data analyses and reports, and creating reimbursement policies and procedures.
  • Coordinated workers compensation cases involving occupational illness or injury via employees, supervisors or workers compensation carrier.
  • Accurately entered and maintained data as required in client database and patient files and utilized the client database to monitor outstanding items on each client case file.
  • Oversaw the operation of claims management for payment and denials.
  • Provided complaint charging practices for all payers by reviewing the medical record for appropriate clinical documentation that support the accuracy of charges.
  • Adhered to quality and production standards and complied with all applicable company, state, and federal safety programs and procedures.
Education and Training
Medical Billing Certification1991
DiplomaDenby High School | 1989
Accomplishments
  • Extensive knowledge of medical terminology across a broad range of medical practice areas.
  • Highly organized and independent; able to effectively coordinate tasks to accomplish projects with timeliness and creativity.
  • Strong understanding of ICD-10 CM and CPT requirements and procedures.
  • Proven ability to work creatively and analytically in a problem-solving environment.
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Resume Overview

School Attended

  • Denby High School

Job Titles Held:

  • Appeals and Grievance Coordinator
  • Senior Appeal Rep
  • Senior Provider Service Rep
  • Reimbursement/WCI Specialist

Degrees

  • Medical Billing Certification
    Diploma

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