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grievance and appeals coordinator resume example with 5+ years of experience

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

Highly resourceful, proactive and customer-centric professional with a track record of inventing ways to attract, delight and retain key customers. Knowledgeable about myriad of products. Gifted in connecting with business customers to meet account needs, drive growth and build retention. Service-oriented and quality-focused with demonstrated success over ten years of experience. Possessing exceptional work ethic and desire to go above and beyond to exceed company expectations. Successful in fast-paced, deadline-driven environments to manage goals and team development.

Skills
  • Microsoft Word, Excel, PowerPoint, Outlook, Vista, Windows XP and the Internet
  • Digital/Social Media Platforms
  • Experience in navigating teams through changing business environments
  • Ten years’ experience in training development, motivation, and team building
  • Exemplary problem-solving skills; able to identify the problem and implement corrective
  • Processes
  • Documentation skills
  • Exceptional recordkeeping abilities
  • Outstanding clerical abilities
  • Working collaboratively
  • Reliable and trustworthy
  • Secure data practices
Experience
Grievance and Appeals Coordinator, 01/2021 - Current
Sysco Columbus, OH,
  • Gather, analyze and resolve verbal and written claims and authorization appeals from providers and pursue resolution of formal grievances from members.
  • Prepare response letters for members and provider complaints, grievances and appeals.
  • Maintain files on individual appeals and grievances.
  • May coordinate the Grievance and Appeals Committee.
  • Support the pay-for-performance programs, including data entry, tracking, organizing, and researching information.
  • Assist with Healthcare Effective Data and Information Set (HEDIS) production functions including data entry, calls to provider's offices, and claims research.
  • Manage large volumes of documents including copying, faxing and scanning incoming mail.
  • Verified policy holder data, including age, contact number and physical address.
  • Manage and advise the organization on development and maintenance of an effective appeals and grievance process.
  • Over a 10 month period I contributed to a 75% reduction in appeal resolution turn-around time and a 150% increase in the monthly closed cases rate.
Customer Service Rep, 12/2019 - 06/2020
Cognizant Technology Solutions Fort Wayne, IN,
  • Coordinated internal research between (4) departments to address client based needs.
  • Developed internal assessments to increase client experience by 40%.
  • Identified steps/solutions for clients questions/issues to increase overall experience by 35% by using appropriate problem-solving skills, organizational policies, and guidelines.
  • Offered additional options to provide positive outcomes for clients for plan benefits to generate increase in revenue by 25%.
  • Followed up with clients to ensure all questions/concerns were resolved to increase retention by 20%.
  • Cultivated impactful relationships with customers and drove business development by delivering product knowledge.
  • Use of Service Level Agreements (SLAs) and Performance Guarantees (PGs) when interacting with clients.
  • Redirected client to appropriate departments based on client need.
  • Mastery of organizational policies and procedures to positively impacting clients.
  • Delivered service and support to each customer, paving way for future business opportunities.
  • De-escalated problematic customer concerns, maintaining calm, friendly demeanor.
  • Achieved an 85% first call resolution success rate with clients.
Social Media Content Analyst, 04/2018 - 11/2019
Cognizant City, STATE,
  • Promoted strong bias for doing right by our communities through social media objectives.
  • Empathetically resolved community driven issues and concerns with accuracy.
  • Investigated/resolved issues reported by the community account support & abusive content.
  • Responded to user inquiries with high quality, speed, empathy, and accuracy.
  • Diligently worked on increasing user experience by 50% by analyzing data.
  • Identified trends and patterns to eliminate issues that violate organizational policy.
  • Monitored replies and comments to expertly assessed criticism, complaints and concerns of current and prospective customers and consumers.
  • Corrected inefficiencies in workflows throughout organization.
Senior Process Executive, 10/2016 - 04/2018
Cognizant City, STATE,
  • Member benefits and eligibility related to the HMO, EPO/PPO, Medicare, Medicaid, and CHIP.
  • Resolved benefits and eligibility issues by conducting internal research.
  • Researched and investigated continuously to pinpoint process improvements needed to elevate company's efficiency and success.
  • Engaged customers to build rapport to increase satisfaction by 30%.
  • Documented vital information by using quality program behaviors.
  • Provided external support to vendors to increase vendor retention by 15%.
  • Observed corporate protocols and procedures to secure sensitive and confidential data.
  • Led orientation for all new hires to ensure customer satisfaction goals were achieved.
  • Conducted trainings on systems training, organization policies, and customer satisfaction to effective grow (CS) teams throughout the organization.
Grievance and Appeal Analyst, 01/2015 - 02/2016
Anthem Inc City, STATE,
  • Ensured members and providers appeals/grievances are investigated according to benefit requirements.
  • Documented inquiry outcomes for accurate tracking and analysis.
  • Developed positive customer relations to ensure customer requests are appropriately handled.
  • Provided state and federal government required documents for grievances and appeals.
  • Served as point of contact with state; managed the day to day operations of the grievance process.
  • Coordinated with network providers to ensure customer needs are fully achieved.
  • Performed claims and trend analysis on customer records to increase satisfaction by 25%.
  • Adhered to company and insurance client's guidelines in claims processes, estimate writing and claim closures.
  • Reviewed policies to determine appropriate levels of coverage and assisted with approval or denial decisions.
Education and Training
Contact Tracer Certification: , Expected in 07/2020
-
Johns Hopkins University - ,
GPA:
Status -
: Computer Science, Expected in
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Georgia Perimeter College - Decatur, Georgia,
GPA:
Status -
High School Diploma: , Expected in 05/2002
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Booker T. Washington High School - Atlanta, GA
GPA:
Status -

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Resume Overview

School Attended

  • Johns Hopkins University
  • Georgia Perimeter College
  • Booker T. Washington High School

Job Titles Held:

  • Grievance and Appeals Coordinator
  • Customer Service Rep
  • Social Media Content Analyst
  • Senior Process Executive
  • Grievance and Appeal Analyst

Degrees

  • Contact Tracer Certification
  • Some College (No Degree)
  • High School Diploma

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