Experience

Health Partners Plans

• United States
• Hospitals and Health Care
• 300 - 400 Employee

• Compliance Auditor II

  • May 2022 - Present



eHealth, Inc.

• United States
• Insurance
• 700 & Above Employee

• Medicare Compliance Specialist

  • Sep 2020 - Present



Independence Blue Cross

• United States
• Insurance
• 700 & Above Employee

• Supervisor of Medicare Appeals & Grievances

  • Jul 2014 - Aug 2016

  Supervise a staff of 20 associates in a demanding, high-volume Medicare Appeals and Grievance department tasked with managing multiple lines of business Acts as a liaison to Care Management Coordination, Claims, Enrollment, Billing, and other departments relative to member Appeals and Grievances. Provides technical support and expertise relative to the preparation of grievance cases. Handle sensitive member when escalated and coordinate communications with both internal and external business partners to resolve issues promptly and efficiently Design individual and team development goals and provide regular feedback to associates and upper management Develop and maintain detailed productivity and quality reports for senior management as well as develop desk procedures Monitors and analyzes workflow trends and develops and implements quality improvement as appropriate to ensure that established productivity, timeliness and accuracy standards are attained in accordance with Corporate, NCQA, CMS, State and client guidelines. Coordinate team building activities for the unit to enhance interdepartmental communication and productivity. Actively participate in CMS audit with preparation and presentation of cases

• Team Lead of Appeals & Grievance

  • Jun 2012 - Jul 2014

  Served as a resource and provided guidance to associates assigned to the grievance process. Triage complex member appeals/grievances and forwarded those with quality concerns for further investigation. Processed member grievances, served as member advocate, responded to related inquiries, and documented the investigative process in the department database. Trained new staff and assisted with performance monitoring. Facilitated the quality-assessment process for the review of appeals and grievance files and generated related staff performance reports. Assured associates followed established procedures and identified policies and procedures in need of development or revision. Reviewed case summaries for accuracy following first and second level committees. Facilitated weekly Grand Rounds meetings with the Specialist. Performs other related duties as assigned.

• Appeals Specialist

  • Jun 2006 - Jun 2012

  Receive case files from the Intake Unit and contact members. Serves as the member’s advocate when requested. Respond to member inquires concerning their appeal. Prepares case files and collect all pertinent data, which may include claims, denial letters, and other clinical information from patient care management and requests medical records from practitioners when needed. Prepare case summary within established time frame. Review completed case with supervisor and forwards file to the committee team. Utilize the Access database to document the investigation process. Prepares files for external review per regulatory guidelines. Communicate committee and/or external reviews overturn decisions to internal operational departments and add the documentation to appeal file. Closes cases in the INFO system and returns file to File Room. Assure that all appeal information is maintained in a confidential manner in compliance with corporate confidentiality standards. Perform other duties as assigned.

• Customer Service Representative

  • Jan 2001 - Jun 2006

  Perform claim/call center functions in a full service center. Service all lines of business for IBC/KHPE/AH products. Service member and provider calls and perform necessary follow-up activities. Handle “sensitive” and “priority” claim issues. Communicate through all modes including e-mail, telephone, word/excel documents and the Internet. Interface with Management, Support Staff, and any other internal/external department to research and resolve claim and or service member and provider issues.