Grievance And Appeals Analyst I Resume Example Company Name

GRIEVANCE AND APPEALS ANALYST I

Professional Summary

Professional strengths:

Skills

FACETS software system
Macess software system
Proficient in Microsoft Office Suites applications including OneDrive, Word 2013, Outlook, PowerPoint and Excel
Types 50 wpm
Alphanumeric data entry 3500 kspm
Educational Summary:
BA, Business Foundations, 2013-current

Work History

Grievance and Appeals Analyst I, 09/2014 to 05/2016
Company Name – City, State

Effectively managed a high-volume of inbound and outbound Medicaid member calls.
Primary duties include, but were not limited to: Reviews, analyzes and processes complex and non-complex grievances and appeals in accordance with Department of Medical Assistance Services (DMAS) regulatory requirements.
Effectively communicated internal policies and claims events requiring written response in clear, understandable language.
Utilized guidelines and review tools such as Macess and FACETS to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize and/or route to nursing and/or medical staff for review.
Analyzes and renders determinations on assigned complex and non-complex grievance and appeal issues.
Serve as a liaison between grievances & appeals and /or medical management, legal, and/or service operations and other internal departments.
Gathered and verified all required customer information for tracking purposes.

Risk Management Claims Assistant, 02/2004 to 04/2008
Company Name – City, State

Gathered all necessary documentation related to Worker's Compensation claims to be routed to assigned Risk Manager for determinations regarding compensability or liability potential on routine cases.
Determines which case files can be closed by reviewing files or researching court records.
Communicates with departmental representatives, vendors, attorneys, and claimants to clarify facts, correct errors in paperwork, and check on employees' work status or status of unpaid bills.
Review claims and other documents submitted by claimants for accuracy, completeness, and timeliness.
Provides clerical support to assigned Risk Manager in claims processing; and performed related work as required.

Medicare Case Management Specialist, 02/2001 to 01/2004
Company Name – City, State

Provide administrative support to Medicare Case Managers.
Schedule transportation for continuity of care appointments.
Maintain monthly data tracking reports for each case managed member to ensure monthly Durable Medical Equipment and supplies are ordered and disbursed in a timely fashion.
Provide accurate benefit information for Medicare/Medicaid plan members using FACETS and Macess.
Answered and quickly redirected up to 20 calls per hour from Case managed Medicare members.
Received and processed medical records requests for Medicare Case Managers
Assisted in the maintenance of medical charts and/or electronic medical record (filing, test results, home care forms).
Determined prior authorizations for medication and outpatient procedures.

Warranty Sales Associate, 04/2008 to 01/2014
Company Name – City, State

Acquired customer information such as demographics, payment method and payment processing information.
Handled 100+calls per day in high volume inbound/outbound call center
Consistently exceeded team sales goals by 10%.
Wrote 25,000$ in business monthly.
Adhered to company ACH time quotas.
Responsible for conducting research to resolve customer questions and concerns regarding various products and minor billing discrepancies.
Conducted team building and productivity meetings as well as administered on floor training and support to new hires.
Increased sales volume by adding 25 accounts per week in the assigned territory.
Analyzed call volume and average call time to monitor Customer Service Representative performance and productivity.

Education

Bachelor of Arts: Marketing, Current
University of Pheonix - City, State

Resume Overview

School Attended

Job Titles Held:

Degrees