FABIENNE STACO

Fort Lauderdale, Florida 954-***-****

ad08uz@r.postjobfree.com https://www.linkedin.com/in/fabiennestaco

SUMMARY

A detail-oriented, resourceful, and highly motivated grievances and appeals analyst with in-depth experience in policy investigations, case presentations, document management, claims evaluation, case reporting, coverage determination, benefit explanations, fraud identification, and implementations. Ensures seamless operations while maintaining high case volumes with accuracy and care. Drives strategic solutions that maintain integrity and deliver quality results. A dynamic problem solver who enables a company to adapt to challenges and needs, build dependable partnerships, and optimize productivity in a fast-paced environment.

EXPERIENCE

HEALTHFIRST, New York, New York

Grievance and Appeals Analyst, 2022-2023

Directed case load and accountable for investigating and resolving member- or provider-initiated cases.

Coordinated with senior specialist to compose appeal responses.

Generated, posted, and attached information to claim files.

Checked documentation for accuracy and validity on updated systems.

Oversaw case development and resolution of non-clinical cases, such as certain types of claim denials, member complaints, and member and provider appeals.

Researched issues, referenced, and understood HF's internal health plans, policies, and procedures to time frame decisions.

Interpreted regulations, resolved cases, made critical decisions, and edited and finalized resolution letters.

Managed all duties within regulatory time frames.

Communicated effectively to hand off or pick up work from colleagues.

Worked within framework that measured productivity and quality for each specialist against expectations.

Verified that the authorized representative listed on the case matched the representative listed in the system.

Validated the information on the Appointment of Representative form for accuracy.

MCNA DENTAL, Ft. Lauderdale, Florida

Grievance and Appeals Administrator, 2014-2021

Led member and provider appeals to ensure that any dissatisfaction voiced by member and provider would be investigated in timely manner.

Conducted investigation and reviewed member grievances and appeals involving provision of service and benefit coverage issues.

Researched administrative or non-clinical aspects of appeal including eligibility, benefit levels, and overall adherence to policies and practices.

Managed written correspondence regarding grievances and appeals in compliance with all Medicaid requirements.

Maintained current knowledge of federal and state laws and rules regarding grievances and appeals.

Contacted members to gather information and communicate disposition of case; documented interactions and contacted provider to obtain medical records.

Oversaw maintenance of grievance and appeals logs and files.

Communicated with Medicaid Fair Hearing according to Medicaid Requirements.

Generated written correspondence to members and providers.

Ensured all time frames were met throughout appeal and that grievances were met.

PRESTIGE HEALTH CHOICE, Palm Beach Gardens, Florida

Provider Appeals Coordinator, 2014

Managed member and provider appeals, under grievance system, including member grievances, appeals requests, and provider claim and disputes.

Investigated reason for denials and explained to management underlying reasons for identified data quality issues.

Maintained accurate, timely, and complete record of appeals in authorization system.

Communicated with providers to resolve problems with appeal requests that were not submitted according to plan's policy.

Ensured compliance with record retention plan according to plan's policy.

Collected and analyzed historical authorization information to incorporate into departmental appeal documentation.

Coordinated and aided with quarterly meetings to report comprehensive list of data quality issues present during given period.

Led presentation of appeals to Appeals Committee and served as member, tracking meeting times and content.

Oversaw communication of decisions in writing made by Appeals Committee to providers within plan's timeframe.

Updated and generated authorizations for services that had been appealed and communicated information to medical claims department.

Identified and reported on provider issues and noted educational opportunities that may be utilized for provider services management staff.

Prepared and developed written case summaries and reports findings for medical director for further review to determine corrective action planning.

HEALTH BUSINESS SOLUTIONS, Cooper City, Florida

Denial Recovery Specialist, 2010-2014

Oversaw hospital claim processing insurance claims, researching cause for rejection and denial, correcting errors that caused rejection or denial, and reprocessing or re-billing claim for payment.

Reviewed explanation of benefits to determine denial type. Researched client data systems to determine current status / past actions on claim. Contacted insurance companies to verify denial reason. Determined appropriate action to resolve denial and documented all actions taken in client and SRS computer systems as appropriate.

Reported Medicare, Medicaid, and third-party payer rejection and or denial “issue” trend to project supervisor.

Contacted insurance companies / patient to gather necessary information to resolve claim. Gathered information requested by insurance company, including medical records and information from ancillary department.

Dropped new claim to billing system for payment.

Wrote letter of appeal, mailed, and followed up.

Requested and posted adjustments on accounts, transferring balance to patient liability when applied.

ADDITIONAL EXPERIENCE

CAREGUIDE, INC., Coral Springs, Florida, Senior Claims Adjudicator, 2001-2010. Adjudicated claims in accordance with company policies, health plan, and CMS standards. Gathered materials needed by auditor(s) for implementation, semi-annual, and annual audits conducted for health plan clients. Served as subject matter expert for claims processors and adjudicators staff. Performed retractions and adjustments of claims. Educated providers on clean claims submissions in accordance with CMS and health plan requirements for claims processing. Answered and directed provider, member, and health plan calls to appropriate area and persons. Assisted manager with special projects and attended meetings as required.

CAREGUIDE, INC., Coral Springs, Florida, Intake Coordinator, 1999-2001. Entered authorization into system for claims processing. Researched member eligibility and benefits. Trained clinical case managers to enter authorizations into system for creation of clinical provider authorizations.

SER / BETA TECH, Fort Lauderdale, Florida, Automated Office Management Intern, 1998-1999

DORLETTE TRAVEL, Oakland Park, Florida, Travel Consultant, 1996-1998. Coordinated travel arrangements, working with operators and other key partners such as hotels and airlines regarding bookings and schedules. Worked with complicated customer itineraries, including handling customer orders, payments, and complaints. Advised clients about passports, vaccinations, foreign currency, travel insurance, car parking, and tours in resorts. Oversaw greeting of customers, scheduling, typing of correspondence, maintaining of client files, faxing, mailing, answering of phone, and data entry. Prepared daily reports for manager. Organized displays of promotional materials.

ST. JOSEPH'S HOSPITAL, Queens, New York, Nurse Assistant, 1994-1995. Worked with nurses and other medical professionals. Observed emotional, mental, and physical conditions of patients, reporting observations to nurses. Determined patients' needs and provided excellent constant care to patients, changing bed linens, bathing patients, dressing / undressing patients, serving / collecting food trays, assisting patients in walking, and transporting patients using wheelchairs. Took and recorded patients' temperature, blood pressure, pulse, respiration rates, and food / fluid intake / output as directed. Oversaw turning and repositioning of bedfast patients, alone or with assistance, to prevent bedsores.

CERTIFICATIONS

SER / BETA TEC, Fort Lauderdale, Florida

American Association of Healthcare, Certified Patient Account Technician

TECHNICAL SKILLS

Claims Adjudication (Skilled Nursing Facilities, Infusion, Home Health, Adult Day, Physician, and DME), HCPCS, ICD9CM and CPT coding. Strong understanding of clinical terminology. Knowledge of EOBS, EOPS, and Auditing. Computer skills include Onbase, Pega, Macess, TruCare, Salesforce, CCMS Software, PMC Software, Health Rules Database, Emdeon Systems, word processing, MS Windows Operating system and MS Office, WordPerfect, Excel, AS / 400, Eclipsys SPFM, Navinet, Jiva, Facets, Exp, Right Fax

LANGUAGES

Fluent in French and Creole.

KEY ACCOMPLISHMENTS

Implemented health rules (claims payment system), health plan delegation auditing, and training of staff on system(s).

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