Team Members Fort Lauderdale
Resume:
Suzanne Lee
Sunrise, FL ***51
*******.******@*****.***
Objective: To maintain a professional and challenging position for potential growth and advancement.
Skills: Leads and directs others, counsels/coaches; manages conflicts; helps team members set and achieves goal; analytical thinking, organizational skills, and people oriented. Experience:
Molina Healthcare Grievances and Appeals Adminstrator Remote
November 2022-March 2024
Ensures that any dissatisfaction voiced by a member will be investigated by the appropriate parties and resolved in a timely manner and ensures that accrediting organizations and Medicaid and Medicare requirements and time frames for grievances and appeals are met. Conducts investigation and review of member grievances and appeals involving provision of service and benefit coverage issues.
United Healthcare Grievances and Appeals Administrator MCNA Dental (Managed Care of North America Fort Lauderdale, Fl) October 2015-November 2022
Implements and provides oversight to the grievances and appeals process and ensures State and Federal compliance. Ensures that any dissatisfaction voiced by a member will be investigated by the appropriate parties and resolved in a timely manner and ensures that accrediting organizations and Medicaid and Medicare requirements and time frames for grievances and appeals are met. Conducts investigation and review of member grievances and appeals involving provision of service and benefit coverage issues. Contacts members to gather information and communicate disposition of case; documents interactions. Generates written correspondence to customers such as members, providers, regulatory agencies and contracted health plans. Researches administrative or non-clinical aspects of the appeal, e.g. eligibility, benefit levels, overall adherence to policies and practices. Maintain current knowledge of federal, state, laws and rules regarding grievance and appeals. Participate in Quality Improvement activities. Carry out all written correspondence regarding grievance and appeals in compliance with all Medicaid requirements. Provides direction to Member Services, Provider Relations and Dental Management departments with issues concerning grievance and appeals. Oversees the maintenance of grievance and appeals logs and files. Humana Health Plans Grievances and Appeals Administrator February 2014-October 2015
Miramar, Fl
Investigate and resolve all members’ appeals and complaints with professionalism and courtesy in a timely manner.
MOSKOWITZ, MANDELL, SALIM & SIMOWITZ Paralegal/Legal Assistant April 2011- October 2015
Fort Lauderdale, Fl
Daily communications with clients through LPS and VendorScape on various request such as executed Affidavits which includes a written statement with the Department of billing, clerks, judicial assistants, and opposing counsels.
AMERICAN EXPRESS COMPANY General Counsel’s Office-Legal Analyst March 1989-April 2011
Plantation, Fl
Resolving and settlement of Small Claims and Superior Court Lawsuits, responsible for intake of all lawsuits, legal demand letters and various regulatory inquiries directed at the company’s response to discovery requests; drafting responses to inquiries from State and Federal regulators; collecting data relating to lawsuits. Providing document production to outside counsel, and excellent knowledge of domestic and international Cardmember Services, managing cost containment, case time resolution, case management and negotiations. EDUCATION:
A.S Business Administration
(Broward Community College) Davie, Fl 1994-1996
Legal Studies
Nova Southeastern University Davie, Fl 1996-2000
HIPPA Certification: Annual Compliance Training
(2-40 Licensed Agent)
References Upon Request
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