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Skills

  • Proficient in SAP
  • Active listening for improved customer interactions
  • Policy change implementation based on trend analysis
  • Team building
  • Team management
  • Organization
  • MS Office
  • Grievance and appeals resolution
  • Business operations
  • Adherence to HIPAA and other confidentiality protocols

Work Experiences

  • Collaborated with external legal teams.
  • Achieved results over 2023 period.
  • Achieved a 22% decision accuracy rate.
  • Achieved a 61% reduction in team error rates.
  • Achieved 28% positive resolutions for customers.
  • Completed resolutions within 3 business days.
  • Had an excellent attendance record and was always on time for work.
  • Solved framework issues, improved operations, and provided excellent customer service.
  • Coached junior specialists on best practices.
  • Collaborated directly with external legal teams to address high-risk cases, contributing to a decrease in litigation by $3 over 2023.

Summaries

  • Overall morale and productivity are boosted by experience in policy development and staff management procedures.
  • Achieved 15% improvements in policy strategies.
  • Achieved a decision accuracy rate of over 43%.
  • Achieved more successful appeal outcomes.
  • Adaptable Grievance Appeals Specialist experienced in managing 4 complex appeals annually, leading to a 16% increase in timely appeal resolutions and enhanced regulatory compliance.
  • Aligned appeal decisions with policies and industry standards.
  • Within Miscellaneous, senior Grievance Appeals Specialist and outstanding performer in team leadership and vendor management.
  • Achieved a 21% improvement in timely resolutions.
  • Grievance Appeals Specialist with 3 years of experience, dedicated to providing personalized, courteous service.
  • Empathy, dependability, and enthusiasm for customer satisfaction.

Accomplishments

  • Directed a team that processed 12 appeals monthly, achieving a case resolution timeliness rate of 71%.
  • Facilitated 11 internal training sessions on grievance handling policies, which led to a 52% improvement in operational compliance.
  • Incorporated grievance analysis into regulatory reporting, ensuring 51% adherence to state and federal compliance rules.
  • Monitored performance metrics of the appeals team, ensuring that 34% of deadlines were met consistently.
  • Oversaw a workflow audit that led to a 28% improvement in appeals response times via automation updates in Workday.
  • Produced detailed reports presenting findings from root cause analysis for 10 legal escalations, influencing policy updates.
  • Reduced internal escalations by 78% through timely grievance resolutions and effective communication with stakeholders.
  • Led the automation of appeals processing for specific cases, resulting in 7 hours saved per week in manual work.
  • Used Microsoft Excel to develop inventory tracking spreadsheets.
  • Drafted and presented findings to senior leadership, leading to policy changes that improved customer satisfaction ratings by 71%.

Affiliations

  • Member of Dispute Resolution Section, American Bar Association (ABA)
  • National Association of Social Workers (NASW) for Appeals and Advocacy Roles
  • Rotary International
  • Society of Human Resource Management
  • Society of Women Engineers
  • American Medical Informatics Association
  • Member of the International Institute for Conflict Prevention & Resolution (CPR)
  • Certified Case Manager (CCM) Professional Membership
  • United States Ombudsman Association (USOA) - Grievance Resolution
  • International Association of Administrative Professionals

Certifications

  • ServSafe
  • Ethics and Compliance Program Certificate – Cedar Works – 2015
  • Conflict Resolution and Mediation in Healthcare Certificate
  • Managed Care Specialist Certification (MCS)
  • Certified Business Analysis Professional (CBAP)
  • Certified Healthcare Claims Professional (CHCP)
  • CompTIA Network+
  • Certified Patient Account Manager (CPAM)
  • SHRM Certified Professional (SHRM-CP)
  • Licensed Utilization Review Agent (LURA) Certification

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