Experience

Amida Care

• United States
• Insurance
• 1 - 100 Employee

• SENIOR APPEALS AND GRIEVANCE COORDINATOR

  • Jun 2014 - Present

  Coordinate investigations of Medicaid and Department of Health complaints for this private, nonprofit community health plan serving more than 8500 members with chronic conditions across NYC. Research, document, and resolve issues in compliance with regulations and policies of the Department of Health (DOH), Centers for Medicare & Medicaid Services (CMS), and the organization. Monitor and track cases to ensure timely completion. Prepare and submit quarterly complaint summary for the NYS Health… Show more Coordinate investigations of Medicaid and Department of Health complaints for this private, nonprofit community health plan serving more than 8500 members with chronic conditions across NYC. Research, document, and resolve issues in compliance with regulations and policies of the Department of Health (DOH), Centers for Medicare & Medicaid Services (CMS), and the organization. Monitor and track cases to ensure timely completion. Prepare and submit quarterly complaint summary for the NYS Health Commerce System. Collaborate across departments and with vendors to coordinate information. Prepare quarterly reports for committee meetings using applicable metrics to identify risks and trends. Engage in continuous process improvement, recommend viable solutions, and provide superior customer service at all times. • Developed new database for appeals and grievances (A&G) in collaboration with IT consultant; executed UAT testing, and serve as contact for resolution of database issues and trouble-shooting. • Create training materials for databases and instruction on processes. • Serve as Change Agent for Amida Care Culture Transformation Project. • Serve on the Amida Care Wellness and Benefits Committees Show less Coordinate investigations of Medicaid and Department of Health complaints for this private, nonprofit community health plan serving more than 8500 members with chronic conditions across NYC. Research, document, and resolve issues in compliance with regulations and policies of the Department of Health (DOH), Centers for Medicare & Medicaid Services (CMS), and the organization. Monitor and track cases to ensure timely completion. Prepare and submit quarterly complaint summary for the NYS Health… Show more Coordinate investigations of Medicaid and Department of Health complaints for this private, nonprofit community health plan serving more than 8500 members with chronic conditions across NYC. Research, document, and resolve issues in compliance with regulations and policies of the Department of Health (DOH), Centers for Medicare & Medicaid Services (CMS), and the organization. Monitor and track cases to ensure timely completion. Prepare and submit quarterly complaint summary for the NYS Health Commerce System. Collaborate across departments and with vendors to coordinate information. Prepare quarterly reports for committee meetings using applicable metrics to identify risks and trends. Engage in continuous process improvement, recommend viable solutions, and provide superior customer service at all times. • Developed new database for appeals and grievances (A&G) in collaboration with IT consultant; executed UAT testing, and serve as contact for resolution of database issues and trouble-shooting. • Create training materials for databases and instruction on processes. • Serve as Change Agent for Amida Care Culture Transformation Project. • Serve on the Amida Care Wellness and Benefits Committees Show less



VNS Health

• United States
• Hospitals and Health Care
• 700 & Above Employee

• Grievance & Appeals

  • 2012 - 2014



PwC

• Professional Services
• 700 & Above Employee

• Consultant

  • Aug 1998 - Jul 2009



Kwasha Lipton

• Ft. Lee, New Jersey

• Supervisor

  • May 1994 - Aug 1998