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grievance and appeals specialist resume example with 2+ 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 - : - -
Education
Expected in 2015 to to
Bachelor of Science: Health Service Administration
 University of Detroit Mercy - Detroit, MI
 GPA:
  • Minor: Leadership
Expected in to to
Bachelor of Science:
Wayne State University - Detroit, MI
 GPA:
Profile

Driven and compassionate professional with four years hands-on experience in fast-paced environments. Focused on developing high standards of practice for effectiveness and implementing necessary changes to programs and policies. Strong decision maker who understands the importance of leadership, work-ethic, and team work.

Professional Experience
03/2016 to 02/2017
Grievance and Appeals Specialist Visiting Nurse Service Of New York – Mountainside, NJ,
Independently conduct thorough investigations of all member and provider correspondence by analyzing all the issues involved and obtaining responses and information from internal and external entities.
Prepare written response and determination letters that appropriately address the issue and that meet all regulatory and NCQA requirements within required timeframes.
Produce routine and adhoc reports on grievances, complaints and appeals from the grievance and appeals database.
Participate in the analysis of grievance, complaints and appeals data and the preparation of narratives, graphs and flowcharts to be utilized for committee presentations, audits, and any internal/external reports.
05/2015 to 02/2016
Care Coordination Support Specialist Long Term Care Partners – Portsmouth, NH,

Enter demographic data, CPT, ICD-9 and diagnostic codes into our internal computer system are entered. Utilize appropriate resources or contact provider offices to clarify information as needed.

Assists with prioritizing, tracking and monitoring critical incidents reporting assures follow up and resolution.

Act as a liaison to providers regarding care processes and a problem solving of any non-clinical issues.

Utilization Management, and Customer Support 
07/2014 to 01/2015
Patient Service Representative (PSR) Valley Health – Winchester, VA,

Develops liaison relationship between patient and hospital by answering patients' questions regarding hospital policies and billing procedures and by obtaining necessary information to efficiently admit and bill for hospital services rendered Under general supervision, registers patients to center. Obtains insurance, medical and demographic data to register, pre-register, admit or pre-admit patients to the center.
09/2013 to 02/2014
Passenger Service Assistant Prospect Airport Services – City, STATE,
Accountable for the safety and comfort of passengers within the limits of sound operational procedures.
Skill Highlights
  • Critical Thinking Proficiency
  • Team Building 
  • Strong Work Ethic
  • Customer Service
  • Data Analysis
  • Investigative Work
  • Microsoft Office
  • HIPPA Compliance 
  • Member-Focus Care
  • Department Specialization
  • Data entry
  • Scheduling/Billing
  • Inpatient/Outpatient
Internships
  • Henry Ford Health System:

Completed 250 hours with the Director of Henry Ford Health System Fairlane Medical Center

Certifications
  • Basic Life Support (BLS)- American Heart Association
Accomplishments
  • Karmanos Cancer Institute Volunteer: Completed more then 100 hours of volunteering in successfully providing quality care assistance
  • University of Detroit Mercy: Completed a full Health Care Emergency Plan
  • University of Detroit Mercy: Completed a full Health Care Marketing Plan

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Resume Overview

School Attended

  • University of Detroit Mercy
  • Wayne State University

Job Titles Held:

  • Grievance and Appeals Specialist
  • Care Coordination Support Specialist
  • Patient Service Representative (PSR)
  • Passenger Service Assistant

Degrees

  • Bachelor of Science
  • Bachelor of Science

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