Grievance and Appeal Manager Resume Example
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GRIEVANCE AND APPEAL MANAGER
Summary
To obtain a position within the healthcare industry that will challenge and utilize my professional abilities to meet the company's goals and objectives.
Skills
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Experience
Grievance and Appeal Manager05/2016 to CurrentAmerisourcebergen Corporation - CorporateMillbrae , CA
- Manages all aspects of the appeal processes related to the intake, triaging, coordination, and documentation of all grievances, complaints and appeals within the department to promote consistency and accuracy.
- Maintains quality control processes to ensure all standards regarding the timely acknowledgement, resolution and documentation of process improvements when required.
- Ensures all regulatory requirements are met regarding the resolution of member grievances, member appeals and provider claim disputes for the Plan's Medicare, Medicaid and Healthcare Exchange lines of business.
- Develop, update and provide ongoing training on Medicare, Medicaid and Healthcare Exchange training materials relative to grievance, appeal and provider claim disputes.
- Maintain and update on an annual basis, or as necessary, appeal and grievance policies, procedures, provider and member correspondence, consistent with regulatory changes.
- Identify opportunities to implement for best practices and process improvement to optimize performance and administrative costs.
- Represent the Health plan at Medicare and Medicare administrative hearing proceedings.
- Offer staff development through the establishment and monitoring of performance goals and performance reviews.
- Provide leadership during all external and internal departmental audits.
- Create and or prepare narratives, reports, or other presentation materials to be used for committee presentations, audits and internal/external reports.
- Coordinate with internal committees (i.e., Quality Improvement Committee (QIC), Executive Management Committee, Cross-Functional, etc.), to review and analyze appeal and grievance trends and recommends corrective action as necessary.
Lead Compliance Specialist04/2016 to Current
- Implemented, documented, and maintained a coordinated legislative and regulatory compliance program that met the expectation of federal and state regulators.
- Researched, developed, and maintained systems to ensure the organization comply with all policy, process, contract, and regulatory requirements.
- Assist with the non-compliance referral process to include tracking and trending analysis.
- Document management, including forms, program communication, manual updates, and fact sheet updates.
- Documented department workflows and assess processes to identify potential process improvements and efficiencies.
- Assisted with implementation of policies and procedures that affect compliance.
- Identified and developed action plans and/or efficiencies in response to trends and risks across all lines of business.
- Managed and prioritized multiple projects and made decisions about their relative priority at any given time.
- Act as a liaison between departments within the organization to resolve any issues regarding contract or legislative changes, contract deliverables, or quality concerns.
- Stayed abreast of current and upcoming regulations, policies and contractual requirements and works with departmental teams accordingly.
- Participated in regulatory reviews and projects.
- Provided recommendations for efficiencies and effectiveness.
- Supported the contract and corporate compliance process.
- Participated in Benefit and Operational Mandate Committees.
Health Plan Auditor10/2014 to 04/2016CarepathrxLongwood (Ahre) , FL
- Participated in annual risk assessments and assisted in the development of the Plan's audit program.
- Developed audit programs and test procedures based on the internal and external regulatory guidelines.
- Conducted independent and objective reviews, provided added value to the business in established timeframes.
- Communicated audit process, audit status, and audit results in a concise and timely manner to Internal Audit management and business leaders.
- Partnered with management to develop and agree upon efficient and effective corrective action plans to address audit findings.
- Proactively worked with various business units to support their efforts to comply with AHCCCS and CMS regulations through communicating opportunities to improve operational processes.
- Reviewed staff work to ensure its adherence with Internal Audit Standards.
- Provided performance feedback to management staff.
- Participated in special projects as needed.
Appeals Coordinator07/2008 to 10/2014TENET HEALTHCity , STATE
- Arbitrated provider claim disputes in accordance with Arizona Health Care Cost Containment System (AHCCCS) guidelines.
- Reviewed, researched and communicated findings to AHCCCS Providers.
- Ensured that applicable statues are applied correctly to responses.
- Assisted in the tracking and trending of provider issues.
- Verified appropriate payments made to providers.
- Represented Plan throughout the AHCCCS State Fair Hearing process.
- Participated in various cross-functional meetings to reduce appeal volume and provider dissatisfaction.
- Researched and resolved Provider Reconsideration Requests and Payment Disputes in accordance with AHCCCS and the Centers for Medicare and Medicaid Services (CMS) regulatory guidelines.
- Prepared files for review by CMS's Independent Review Entity (IRE).
- Contributed to the strategic development of processes to enhance Departmental efficacy.
- Developed written desktops and policies to ensure Departmental compliance with applicable internal and external guidelines.
- Assisted in the training of incoming staff regarding appeals processes.
- Conducted audits of closed cases.
Education and Training
Advantage Healthcare Management, Webinars hosted by the American Academy of Procedure Coders
*Ottawa University, Course Curriculum in General Education
*Aloha Care, Honolulu, Hawaii, Course Curriculum in Medical Terminology and Certified Procedural Coding: General EducationGrossmont CollegeCity, StateGeneral Education
High School DiplomaAcademy of Our Lady of PeaceCity, State
Skills
10-key, administrative, CMS, concise, CPT, Data processing, desktops, Document management, documentation, Executive Management, forms, Functional, Healthcare Management, ICD-10, Internal Audit, leadership, Leadership training, regulatory compliance, materials, Medical Terminology, meetings, Exchange, Microsoft Office Suite, works, performance reviews, policies, presentations, processes, process improvement, Coding, quality, Quality Improvement, quality control, staff development, strategic development, training materials, Typing 50 WPM, written
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Resume Overview
School Attended
- Grossmont College
- Academy of Our Lady of Peace
Job Titles Held:
- Grievance and Appeal Manager
- Lead Compliance Specialist
- Health Plan Auditor
- Appeals Coordinator
Degrees
- Advantage Healthcare Management, Webinars hosted by the American Academy of Procedure Coders
*Ottawa University, Course Curriculum in General Education
*Aloha Care, Honolulu, Hawaii, Course Curriculum in Medical Terminology and Certified Procedural Coding : General Education
High School Diploma
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