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grievance coordinator resume example with 14+ 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

Committed job seeker with a history of meeting company needs with consistent and organized practices. Skilled in working under pressure and adapting to new situations and challenges to best enhance the organizational brand.

Skills
  • Safety and compliance
  • MS Office
  • Knowledge of OHP benefits
  • Written and verbal communication
  • Process improvement
  • Understanding of prior-authorizations and claims/billing
  • Project organization
  • Team management
  • Organization
  • Knowledge of Medicaid and Medicare rules
  • Good Work Ethic
  • Flexible Schedule
  • Organizational Skills
Experience
Grievance Coordinator, 07/2022 - Current
Wellpath Thornton, PA,
  • Handle and resolve CTM complaints, SHIP escalated issues, and GCR requests received via HPMS CTM, email, mail correspondence, and inbound/outboundphone calls
  • Logs, tracks, resolves and responds to all assigned complaints and inquires in writing and/or by telephone in a timely and professional manner to members, providers, CMS, SPAP/SHIP
  • Assist in the education of new members and in the re-education of existing members regarding health plan procedures
  • Communicate research and resolution to CMS, SPAP/SHIP representatives, and stakeholders
  • Act as a liaison between internal departments and external partners on data gathering and problem solving by investigating and present proposed solutions in a clear and concise manner
  • Identify trends, monitor the root cause of member/provider issues, and work cross functionally with all departments to ensure enterprise wide solutions
  • Efficiently and effectively, maintain a high caseload while meeting and exceeding all performance standards
Senior Customer Representative, 02/2020 - 07/2022
Fedex Cross Border Crofton, MD,
  • Work within a call center environment to process incoming and outgoing telephonic contacts with providers
  • Adhere to workforce management schedules in order to ensure departmental goals are met
  • Conduct inbound telephonic contact with providers in a professional manner and maintain phone stats according to departmental goals
  • Assist Medicaid, Medicare and HIX providers with identified needs during telephonic contacts
  • Determine if procedures require prior authorization by checking CPT codes at the request of providers
  • Assist providers by entering authorizations over the phone, when applicable
  • Educate providers on MHP policies and procedures regarding access to care, grievance and appeal process, eligibility process, HIPAA, rights and responsibilities, and fraud, waste and abuse
  • Remain updated on all provider policy changes made by MHP, the State, or accrediting entities
  • Perform accurate data entry into MHP systems and software programs
  • Consistently demonstrates compliance with HIPAA regulations, professional conduct and ethical practice
  • Gather, analyze, and report documentation for verbal, written, and expedited member and provider complaints
  • Prepare and report documentation supporting verbal and written provider claims and pre-authorizations.
Office Medical Assistant/Coordinator, 01/2019 - 01/2020
Beaumont Health System City, STATE,
  • Enhanced patient outcomes by providing knowledgeable education on procedures, medications and other physician instructions
  • Completed clinical procedures and gathered patient data for interpretation by physician
  • Maintained detailed records of test results by entering data and patient information into computer
  • Processed claims information for patients receiving bills, pre-authorization requirements, and appeals
  • Prepared resolution letters for patients and the health plan
  • Obtained client medical history, including medication information, symptoms and allergies
  • Oriented and trained new staff on proper procedures and policies
  • Explained procedures to patients to reduce anxieties and increase patient cooperation
  • Updated inventory, expiration and vaccine logs to maintain current tracking documentation
  • Communicated clearly and effectively with patients to verify information, determine purpose of visit and record medical history
  • Educated patients by providing medication and diet information and clarifying physicians' orders, answering questions thoroughly
  • Interacted and communicated with departments personnel, and medical providers, and patients
  • Protected patients and staff from infection risks by routinely cleaning and disinfecting common areas and patient rooms
  • Collected and documented patient medical information such as blood pressure and weight
  • Collected histories, vitals and current complaints via patient interviews.
Oncology Care Associate, 02/2008 - 01/2019
Karmanos Cancer Institute City, STATE,
  • Monitored and maintained cleanliness, sanitation, and organization of assigned station and service areas
  • Monitored and assisted residents through individual service plans
  • Recorded vital signs, such as temperature, blood pressure, pulse, or respiration rate, as directed by medical or nursing staff
  • Documented residents' behavior in terms of mental status, sleeping and eating patterns in medical record books
  • Determined specific needs and provided most appropriate level of services for patient well-being
  • Remained alert to problems or health issues of clients and competently responded
  • Recognized and reported abnormalities and/or changes in patients' health status to case manager.
Education and Training
MBA: Business Administration, Expected in 02/2023
-
University of Phoenix - Tempe, AZ
GPA:
Status -
Bachelor of Science: Healthcare Management, Expected in 08/2021
-
University of Phoenix - Tempe, AZ
GPA:
Status -
Associate of Science: General Studies, Expected in 05/2014
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Wayne County Community College District - Detroit, MI
GPA:
Status -
Activities and Honors
Enthusiastic Grievance Coordinator with more than two years’ experience in a Health Insurance Company environment. Primarily focusing on Illinois and Michigan Health Plan and grievances. Skilled in receiving, routing, filing, and delivering a wide range of medical documentation.

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Resume Overview

School Attended

  • University of Phoenix
  • University of Phoenix
  • Wayne County Community College District

Job Titles Held:

  • Grievance Coordinator
  • Senior Customer Representative
  • Office Medical Assistant/Coordinator
  • Oncology Care Associate

Degrees

  • MBA
  • Bachelor of Science
  • Associate of Science

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