Grievance and Appeals

Lisa M. Woods

Columbus, OH 614-***-**** ********@*****.***

Results-Oriented Manager with Managed Care Experience

High-performing professional with valuable experience in leadership, completing claims auditing, monitoring, as well as verification activities. Ensures effectiveness and customer satisfaction by reviewing claims processing practices, ensuring regulatory compliance, and making recommendations for process improvements. Possesses highly transferable expertise in driving effective results and directing workflow to ensure timely as well as accurate processing, simultaneously meeting organizational objectives and regulatory requirements. Capable of developing effective and professional working relationships with internal and external stakeholders as well as partners. Demonstrates ability to apply project management skills and coordinate activities across multiple departments to drive successful project completion and support initiatives related to quality, training, and process improvement. Showcases excellent organizational, analytical, and interpersonal skills as well as thorough knowledge of customer service, appeals review, and claims processing practices in a managed healthcare environment. Eager to master new challenges and assume a leadership role by ensuring compliance and assisting in the collection of information to drive necessary regulatory compliance activities. Five years of experience in managing teams of up to 25 people.

CORE COMPETENCIES

Claims adjudication

Customer service

Medical terminology

Project management

Auditing

Results-driven

Analytical thinking

Communication skills

Multitasking

Problem-solving

Leadership skills

Negotiation skills

Talent development

Process improvement

Decision making

PROFESSIONAL EXPERIENCE

Catalyst Solutions 12/21- 11/23

Greenwood Village, CO- Remote

Associate Manager, Client Engagement

Solution-focused Engagement Manager dedicated to building and strengthening relationships with clients and staff.

Manage, mentor, and coach consultants with a collaborative approach. Trusted advisor to clients by meeting or exceeding expectations and problem-solving. Conduct one on ones with consultants bi-weekly to ensure client’s expectations are met, address work performance, and disciplinary action if necessary. Drive the success of assigned resources by actively managing the outcomes of individual contributors and staying ahead of issues/risks.

Develop, manage, and maintain relationships with clients from kick off stage to offboarding of project

Manage individual consultants, including analysis of reports that indicated quality and productivity

Work closely with various departments and teams to develop accurate resourcing plans and role requirements for new and existing projects

Effectively present issues and problem-solving solutions to clients, consultants, and internal peers

Communicate issues and concerns to senior leaders and/or clients in a timely manner and develop risk mitigation plans, as necessary

Work closely with back-office departments to implement on and offboarding clients and consultants

Maintain a portfolio of client overseeing deliverables according to the Statement of Work (SOW)

Buckeye Health Plan 10/14 – 11/21

Columbus, OH

Grievance and Appeals Coordinator II 05/18 – 11/21

Lead coordinator goal-oriented appeals coordinator with a key role in analyzing, researching, resolving, and responding to complaints, appeals, and grievances from members, providers, as well as regulatory agencies within established regulatory guidelines. Proven track record of success in researching cases, applying critical thinking, independent judgment, and business sense to make final appeals determinations, and providing comprehensive responses within regulatory timeframes. Demonstrates problem-solving and complaint-resolution abilities by conducting information analysis and evaluation as well as implementing solutions derived from appeal cases.

Reviewed and processed member and provider grievances and appeals within federal, state, and organizational regulations, policies, and procedures; conducted weekly/monthly documentation audits

Consulted with clinical and legal subject matter experts to assure compliance of appeals and complaints decisions with determined guidelines, resulting in a high rate of customer satisfaction

Communicated with members and providers as required to coordinate statuses, processes, and outcomes of complaints as well as appeals and grievances

Provided the necessary direction to new and existing staff members regarding the grievance and appeals process, simultaneously assisting in the supervision of teams to ensure the highest efficiency and accuracy

Denial Coordinator 02/17 – 05/18

Dedicated denial coordinator accountable for the medical management of the denial process to ensure compliance.

Processed verbal and written cases from member and provider appeals and complaints about all lines of business, ensuring compliance with applicable policies, procedures, and other governing bodies. Demonstrated advanced analytical as well as research skills utilized in gathering additional information and handling complex provider issues, concurrently ensuring prompt resolution and provider satisfaction.

Contacted members and providers to seek additional information or clarification regarding grievance and appeals cases

Developed training materials, implemented quality assurance processes, and served as a resource expert on appeal procedures for the team members

Proactively collaborated with internal departments and tracked information to facilitate and expedite the processing of received appeals

Produced and managed resolution letters with determination responses while adhering to required timeframes

Used exceptional problem-solving skills and department resources to identify all issues within a case, appropriately categorize cases, and take required actions in accordance with state and federal regulations

Program Coordinator I 12/15 – 02/17

Accomplished program coordinator in charge of assisting in activities related to the medical aspects of utilization and coordinated care. Provided hands-on management and delivery of a broad portfolio of activities, including handling planning and coordination of 3,000 Buckeye members and their activities in three regions, initiating discharged skilled nursing authorizations, and investigating provider claims issues. Provided guidance to providers in handling policies and procedures related to referrals and claims submission. Resource expert on dual Medicare program.

Successfully exceeded a goal for authorization load error report of 5% in 2016

Evaluated and monitored inpatient census and screened member’s eligibility as well as benefits

Surpassed a monthly goal for building and sending three-day authorizations and pended claims

Supported the pay-for-performance programs, including data entry, tracking, organizing, and researching for information

Healthcheck Coordinator II 10/14 – 12/15

Motivated healthcheck coordinator adept at conducting outreach to encourage enrollees to access preventive care. Presented the importance of regular preventive healthcare and assisted with making appointments and arrangements for healthcare screening. Handled various responsibilities such as data entry, explaining insurance benefits to the potential enrollees, and implementing “HIPAA” policies and regulations for medical information protection.

Served as a subject matter expert for EPSDT program and educated team members on HEDIS and EPSDT principles

Provided leadership and oversight to a new outbound call center for Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)

Created training materials and provided continuous education to the outbound representatives while providing feedback to senior management

Continually assisted in the implementation of quality improvement initiatives in the customer service and clinical areas

PREVIOUS EXPERIENCE

Appeals Specialist 06/13 – 10/13

Kelly Services Columbus, OH

Client Service Specialist 01/09 – 08/12

Progressive Medical Inc. Westerville, OH

EDUCATION

Bachelor of Science in Business Administration, 2017

Western Governors University - 66 credits completed

Buckeye Health Plan

Buckeye Health Plan

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