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Skills

  • Regulatory compliance
  • Relationship development
  • Clinical and regulatory appeals review
  • Grievance and appeals management
  • Business operations
  • Data gathering and reporting using Salesforce
  • Cost-saving strategies in resolution processes
  • Motivating teams to meet resolution goals
  • Audit and ensure compliance with policies
  • Team building

Work Experiences

  • Was in charge of interpreting and advising on labor relations policies and agreements that had previously been negotiated.
  • Addressed internal grievances.
  • Awarded PMP in Appeals and Grievance Handling.
  • Consistently met 60% or above the monthly resolution targets for grievances, contributing to improved member satisfaction ratings by 47%.
  • Had an excellent attendance record and was always on time for work.
  • Achieved a 70% increase in timely resolutions.
  • Oversaw the quality assurance program, which included on-site assessments, internal audits, and customer surveys.
  • Complied with initiative standards.
  • Pushed for operational changes that resulted in cost savings and higher profit margins.
  • Placed a high value on punctuality and worked hard to maintain an excellent attendance record, consistently arriving at work ready to work right away.

Summaries

  • Collaborated with regulatory and legal experts.
  • Accomplished in developing case tracking systems.
  • Dedicated to learning, growing, and succeeding in Miscellaneous.
  • Desire to apply existing skills to a new position with room for growth.
  • Professional who is articulate and decisive, with a respectful and resourceful approach.
  • Achieved a 24% pass rate on compliance audits.
  • Analyzed grievance outcomes.
  • Strengths in stakeholder engagement and quality assurance backed up by Miscellaneous training.
  • Achieved a 71% improvement in member satisfaction.
  • Applied complex regulatory frameworks effectively.

Accomplishments

  • Consistently exceeded 66% of monthly grievance resolution targets, resulting in a 74% improvement in member satisfaction ratings.
  • Successfully handled 4% of member appeal escalations involving complex policy interpretations, leading to positive satisfaction scores across surveys.
  • Successfully spearheaded the upgrade of case management software, reducing average processing time by 5% and improving overall workload balance.
  • Guided departmental leaders on compliance adjustments, which minimized the risk of legal infractions and saved Brightline potential fines of 10.
  • Increased appeals team productivity by 72% through comprehensive trainings and workflow optimizations with measurable compliance improvements.
  • Reduced average escalation response time by 15% after implementing a new real-time tracking system using ServiceNow.
  • Introduced a streamlined digital filing system that decreased case review time by 17% and amplified case retrieval efficiency.
  • Collaborated with human resources to resolve escalated appeals, creating a cross-functional task force that improved resolution success by 80%.
  • Trained and onboarded new team members in the use of ServiceNow, leading to marked improvement in case accuracy and resolution speed by 35%.
  • Led compliance training sessions for a team of 17 appeals coordinators, ensuring full adherence to Miscellaneous regulatory mandates and guidelines.

Affiliations

  • Healthcare Risk Management Certification via American Society for Healthcare Risk Management (ASHRM)
  • Continuing Education with American Case Management Association (ACMA)
  • Volunteer contributor to Medicaid Appeals and Complaints Department (specific to Chicago)
  • Appeals and Grievances Interest Group - America’s Health Insurance Plans (AHIP)
  • Jaycees
  • Corporate Compliance and Appeals Committee - Health Plan Alliance
  • Active participant in National Association of Healthcare Quality (NAHQ)
  • Society for Human Resource Management (SHRM) member - focusing on employee grievances
  • Certified in Health Insurance Present on Admission (HIPA)
  • Certified HIPAA Privacy Expert (CHPE) participation

Certifications

  • Patient Advocacy and Complaint Resolution Certification
  • Certified Managed Care Professional (CMCP)
  • Certified Appeals and Grievances Coordinator (CAGC) – Ironclad Systems
  • Certified Business Analysis Professional (CBAP)
  • Certified Healthcare Marketing Professional (CHMP)
  • Cisco Certified Internetwork Expert (CCIE)
  • Certified Managed Care Executive (CMCE)
  • Appeals and Grievances Process Certified (AGPC) – Portland
  • Certified Healthcare Customer Service Representative (CHCSR) – 2017
  • Lean Six Sigma Green Belt – Healthcare Focus

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