senior grievance and appeal administrator resume example with 19+ years of experience

Jessica Claire
  • Montgomery Street, San Francisco, CA 94105 609 Johnson Ave., 49204, Tulsa, OK
  • Home: (555) 432-1000
  • Cell:

Proactive, results-driven professional with a solid track record of demonstrated leadership strengths and proven ability to manage multiple responsibilities in a fast-paced environment with critical deadlines. Well organized individual with 10 + years experience in health care administration. Works well independently or collaboratively in a team setting. Thrives on identifying problems and implementing innovative solutions through process improvement.

  • Health care administrative professional with a substantial work history in a variety of insurance and health care settings.
  • Excellent oral and written communication skills.
  • Computer literate in Word, Excel, PowerPoint
  • Familiar with data analysis and interpretation
  • Well versed in Medicare & Medicaid, OHP & DSHS
  • Critical thinker with sound decision making and analytical skills
  • Knowledgeable concerning ICD 10, HCPCS, HEDIS, CHAPS NCQA and HIPPA
  • Culturally sensitive, team player who with an extensive background in medical terminology.
  • Highly organized, quick learner, able to work independently and effectively prioritize and manage multiple tasks.
  • Strong work history in the areas of risk management and the resolution of complex member issues.
Senior Grievance and Appeal Administrator, 11/2001 to Current
Kaiser Foundations Health Plan And HospitalsCity, STATE,
  • Decreases plan exposure to bad faith or breach of contract lawsuits, regulatory sanctions, penalties and adverse media exposure by effectively managing and resolving a heavy volume of complex, sometimes sensitive, highly regulated complaints, grievances and appeals in compliance with state and federal laws, internal policies, best practices and principles.
  • Very skilled in the areas of critical thinking, problem solving and making sound decisions under pressure.
  • Advocacy Works earnestly to enhance member retention during the course of resolving complaints by identifying and reporting contractual deficiencies, member/provider fraud or abuse, and adverse trends occurring within the organization at the administrative or clinical level by escalating issue to the appropriate senior leader.
  • Offer specific assistance to members/patients who are not proficient in English or have other special needs.
  • Ensure all complaints including sentinel or never events are escalated according to policy.
  • Research and Investigation Enthusiastically researches, responds and resolves complex, litigious and sensitive complaints for President and other senior leaders in a voice that reflects the organization's values, mission and commitment to patient population and community with transparency and integrity to facilitate a viable solution and mitigate damages while protecting the patient's rights and organization's viability.
  • Impacts sustainable improvement through use of root cause analysis, systems-thinking, and trend analysis.
  • Case Management/Conflict Resolution Assists care delivery managers and physicians develop a plan of action for managing difficult, abusive or noncomplying patients by being present during care conferences, developing behavioral contracts, following-up with patient or patient's family/caregiver, share information regarding community resources, work to identify underlying mental health, cognitive or environmental factors inherent to the patients situation to protect staff, facilitate the delivery of quality medical care, and enhance the overall patient experience.
  • Outreach Contacts patient and non-plan providers, when appropriate, to give them an opportunity to express their voice and provide additional information about their case for inclusion and consideration in the decision-making process.
  • Educating, service recovery and maintaining customer loyalty through outreach and response.
  • Legal, Regulatory and Compliance Responds orally and in writing to formal investigations initiated by the Office of Personnel Management (OPM), Washington or Oregon Insurance Divisions, public figures, and other agencies, concerning Health Plan's position, contract interpretation, benefits administration, internal criteria, research analysis, and clinical basis for care decisions such as SNF desertification, referral denial, post-stabilization care, internalization of care, hospital discharges, and pharmaceutical disputes.
  • Collaboration/Teamwork Supports risk management and legal personnel in the process of collecting documentation, writing detailed summaries and compiling medical records and supporting documentation for cases subject to or in litigation proceedings, including representing health plan in testimonials or depositions.

Highly experienced in member management and conflict resolution

Excellent critical thinking and problem solving abilities

Familiar with various aspects of risk management

Strong oral and written communication skills

Contract interpretation and benefit administration

Advanced knowledge in quality assurance standards, HIPPA, ERISA, state, federal, OSHA regulations, health care reform and other regulatory and legal requirements

Experienced in staff training/motivation/development

  • Consistently meets deadlines, compliance and regulatory standards.
  • Volunteered to participate in process improvement work group to isolate the root causes of performance issues and identify potential solutions to eliminate the problem and gain efficiencies.
  • Assisted in implementation of a new project that enables employees to telecommute and a system of measurement for tracking productivity, accountability and adherence to the organization's performance, confidentiality and compliance requirements.
  • Ensures the timely resolution of assigned cases and accuracy of written documentation by engaging with and supporting team members in training endeavors and weekly process improvement activities raising performance scores to meet departmental goals.
  • Project member in the company's migration to a national claims administration platform.
  • Participates in the quarterly review and update of user guides, intranet, written policies and procedures to improve performance.
  • Project participant in the creation and revision of letter templates used for communicating health plan decisions to patients, physicians, attorneys, regulatory, and legal entities to ensure adherence to HIPPA, ERISA, state, federal and PPACA mandates.
Bachelor of Arts: Business Administration, Expected in 2011
American Intercontinental University - Schaumburg, IL
GPA: Magna Cum Laude

Graduated Summa Cum Laude

MBA: Health Care Management, Expected in
Marylhurst University - Lake Oswego, OR

Anticipated 03/2016


American Hospital Association (AHA)

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Resume Overview

School Attended

  • American Intercontinental University
  • Marylhurst University

Job Titles Held:

  • Senior Grievance and Appeal Administrator


  • Bachelor of Arts
  • MBA

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