Manager Complaints Appeals Correspondence Team Resume Example

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Jessica Claire
, , 100 Montgomery St. 10th Floor (555) 432-1000,

Highly skilled managerial professional with 18 years of experience in operations, team management, regulatory compliance and strategic planning. Results-oriented, decisive leader with proven success in executing valuable process enhancements. Logical and focused in dynamic and unpredictable circumstances.

  • Leadership
  • Microsoft Office
  • Data Management
  • Operation Management
  • Analytical
03/2020 to Current Manager/ Complaints & Appeals/Correspondence Team Anthem, Inc. | Brooklyn, NY,
  • Provided support with the transition and execution of the Behavioral Health program from Beacon Health to Horizon.
  • Oversees and lead a team of eleven in the Correspondence and Appeals Department.
  • Implemented workflows develop and prioritize training plans for the Behavioral Correspondence and Appeal team.
  • Ensured compliance with company policies and procedures; led staff training initiatives to maximize productivity
  • Directed daily operations including financial, human resources, marketing, inventory control, and customer relations to generate optimal revenue streams for the business.
  • Maintained a positive work environment by implementing personnel actions such as employee initiatives, evaluations, or disciplinary actions.
09/2016 to 04/2020 Supervisor/ Correspondence and Telephonic Team Horizon Blue Cross Blue Shield Of NJ | City, STATE,
  • Oversaw a staff of twenty-six Correspondence and Phones Team.
  • Managed and oversaw daily work to ensured daily receipts are handled in accordance with Service Level Agreements (SLAs) based on order of receipt and escalated issues.
  • Complied with company policies, objectives and communication goals.
  • Solved customer complaints and adjusted policies to meet changing needs.
  • Recognized and corrected performance and personnel issues to reduce impact to business operations.
  • Provided ongoing training to address staff needs.
  • Identified and corrected performance and personnel issues to reduce impact to business operations.
07/2014 to 09/2016 Provider Network Manager EmblemHealth | City, STATE,
  • Primary liaison between EmblemHealth and Montefiore Network and St. Barnabas Hospital
  • Monitored joint contract compliance and operation performances.
  • Evaluated, negotiated and recommended necessary changes to existing contracts ensuring that targeted provider performance and financial goals were met.
  • Met regularly with facility practices in assigned area and established excellent working relationships with staff and promoting the benefits belonging to the EmblemHealth network.
  • Facilitated the timely Credentialing and Re-Credentialing efforts of our Network providers.
  • Managed information flow to and from facilities.
  • Managed and conducted all face to face meetings along with on-site trainings.
02/2013 to 07/2014 Manager/Grievance and Appeals EmblemHealth | City, STATE,
  • Managed a team of twenty-two Appeals Specialist daily operations.
  • Handled the appeal processes related to intake, triaging, coordination and documentation grievances and appeals with the department to promote consistency and accuracy.
  • Make certain regulatory requirements regarding the resolution of member grievances/appeals were maintained.
  • Complied with confidentiality regulations in handling customer information.
  • Organized Grievance & Appeals committee meetings to determine appropriate and consistent methods for grievance and appeals resolutions.
  • Worked in partnership with staff members to manage large volume of appeals.
07/2011 to 04/2013 Sr. Business Systems & QA Analyst EmblemHealth | City, STATE,

· Provided project-level analysis and produced required project analysis documentation.

· Recommended controls by identifying problems and writing improved procedures.

· Prioritized and organized tasks to efficiently accomplish service goals.

· Managed multiple projects and tasks to ensure high quality and timely delivery.

Created and managed project plans while providing status updates to management.

09/2003 to 04/2011 Sr. Delegation Relationship Mgr. EmblemHealth | City, STATE,
  • Responsible for maintaining Healthcare Partners, Davis Vision and the Chiropractic Network partnership.
  • Led support for Provider survey, including input all data and provide additional support as needed
  • Developed relationships with delegate by participating in meetings onsite and at client locations.
  • Drove client satisfaction by utilizing my leadership and management skills and keeping lines of communication open.
  • Managed contract administration, including maintaining files, validating codes and monitoring reporting.
  • Handled and reported Improvement Action Plans (IAP) to the Company Boards of my findings and provide reason for continued delegation.
Education and Training
Expected in 2013 Bachelors of Science | Business Administration, Healthcare Management Colorado Technical University, Colorado Springs, CO GPA:
Expected in 2011 | Business Administration, Healthcare Management Long Island University, Brooklyn, NY GPA:

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Resume Strength

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Resume Overview

School Attended
  • Colorado Technical University
  • Long Island University
Job Titles Held:
  • Manager/ Complaints & Appeals/Correspondence Team
  • Supervisor/ Correspondence and Telephonic Team
  • Provider Network Manager
  • Manager/Grievance and Appeals
  • Sr. Business Systems & QA Analyst
  • Sr. Delegation Relationship Mgr.
  • Bachelors of Science