Grievance And Appeals Coordinator Resume Example Cenpatico

GRIEVANCE AND APPEALS COORDINATOR

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

Grievance and Appeals Coordinator, 10/2015 to Current
Cenpatico – Austin, TX

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

Claim Support Liaison, 01/2015 to 10/2015
Cenpatico – Austin, 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

Customer Service Representative, 08/2013 to 01/2015
Cenpatico – Austin, TX

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

Customer Service Representative, 01/2012 to 08/2013
Maximus – Austin, TX

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

Cashier/Customer Service Representative, 09/2011 to 01/2012
La Mexicana Store – Kyle, TX

Greeting customers
Maintaining a clean environment
Cashiering
Bagging
Stacker

Education

Associate of Arts: Current
Austin Community College - Austin, TX

High School Diploma: 2011
Lehman High School - Kyle, TX

Resume Overview

Companies Worked For:

Cenpatico
Maximus
La Mexicana Store

School Attended

Austin Community College
Lehman High School

Job Titles Held:

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

Degrees

Associate of Arts : Current
High School Diploma : 2011

Grievance and Appeals Coordinator Resume Example

Resume Score: 70%

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