LiveCareer-Resume

grievance and appeals coordinator resume example with 9+ years of experience

Jessica Claire
Montgomery Street, San Francisco, CA 94105 609 Johnson Ave., 49204, Tulsa, OK
Home: (555) 432-1000 - Cell: - resumesample@example.com - -
Professional Summary

Innovative, customer-oriented healthcare administrator with background of 4+ years in managed care. Strong background in quality assurance, claims analysis, grievances and appeals. Skilled at communicating, organizing and solving problems to raise the rankings of health care quality.


Skills
  • Knowledge of Medicaid statutes and regulations
  • Medicaid Management Information Systems
  • Health Care
  • Customer Service
  • 4+ years in Managed Care
  • High quality work
  • Medical Insurance Claims
  • Effective problem solver
  • Computer proficient 
  • Good eye for detail
  • Well organized
  • Strong data entry skills
Work History
09/2015 to Current
Grievance and Appeals Coordinator Core Mark Allentown, PA,
  • Gather, analyze and report verbal and written member and provider complaints, grievances and appeals
  • Prepare response letters for member and provider complaints, grievances and appeals
  • Maintain files on individual appeals and grievances
  • Develop and maintain positive customer relations with internal and external customers and coordinate with various functions within the company to ensure problems, requests, and questions are resolved timely
  • Receive and place follow up telephone calls / emails to answer internal and external customer questions that are routine in nature
  • Support the pay-for-performance programs, including data entry, tracking, organizing, and researching information
  • Assist with 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



2015 to 09/2015
Claim Support Liaison Core Mark Amarillo, TX,
  • Respond to telephone inquiries and initiate steps to assist callers
  • Research claim payment issues to identify root cause and trends to reduce incorrect payments
  • Thoroughly document information, activities, and changes in database
  • Develop and maintain positive customer relations with internal and external customers and coordinate with various functions within the company to ensure problems, requests, and questions are resolved timely
  • Receive and place follow up telephone calls / emails to answer internal and external customer questions that are routine in nature
  • Relay complex claims support issues to other functions within the Client Support Services area



07/2013 to 2015
Customer Service Representative Cenpatico City, STATE,
  • Answer provider and members inquiries
  • Offer customer service to different states in US regarding Behavioral Health
  • Research and provide information regarding member's eligibility, benefits, referrals, authorizations, and claims
  • Provide members with information on the Provider Network and how to contact and access providers
  • Provide back-up support to Data Entry/Claim team as necessary
  • Document all members' issues and resolution in the computer systems
  • Initiate or fax necessary forms to providers for outpatient therapy services




2012 to 07/2013
Customer Service Representative Maximus City, STATE,
  • Verify member eligibility
  • Refer members on the medical plan to providers
  • Authorize care for Medicaid clients with new children
  • Re-enroll members into the medical plan
  • Provides support to customers, handled inquiries, and provided solutions ·         Perform data entry associated with the position
  • Assist with Medicaid applications
  • Resolve customer complaints efficiently



08/2011 to 2012
Cashier/Customer Service Representative La Mexicana Store City, STATE,
  • Greeting customers
  • Maintaining a clean environment
  • Cashiering
  • Bagging
  • Stacker



Education
Expected in Current
Associate of Arts:
Austin Community College - Austin, TX
GPA:

Expected in 2011
High School Diploma:
Lehman High School - Kyle, TX
GPA:

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Resume Overview

School Attended

  • Austin Community College
  • Lehman High School

Job Titles Held:

  • Grievance and Appeals Coordinator
  • Claim Support Liaison
  • Customer Service Representative
  • Customer Service Representative
  • Cashier/Customer Service Representative

Degrees

  • Associate of Arts
  • High School Diploma

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