Complaint and Appeals Coordinator

Tanesha Orange

Jacksonville, FL ***** *************@*****.*** 215-***-****

I am a champion of human advocacy; who enjoys the thrill of assisting others in reaching the desired outcome. Therefore, I have chosen a career in HealthCare. I want to become the person others look towards to give them the knowledge, understanding and drive they need to make the best decisions for themselves and those around them. Success is not measured by what I did alone but how I was able to positively influence those around me. By keeping this kind of mind frame my contribution to your company will be exciting, rewarding and fulfilling. I want to always progress to the next best level in all that I do. I am never satisfied with being stagnant. I enjoy coming up with new ideas that influence change and making a legacy for others to follow.

Work Experience

Complaint and Appeals Coordinator for Medicare (Part C)

Aetna Inc. a CVS Company - Jacksonville, FL

January 2019 to Present

· Capitalized on opportunities to enhance member and provider experiences by offering optimal levels of service daily

· Excelled in exceeding departmental goals in accordance to CMS and federal guidelines.

· Resolved service problems by clarifying member or provider complaints and determining optimal solutions.

· Provided excellent services to members and providers by following up on issues, concerning a denial of medical or prescription coverage.

· Communicated with members and providers via email, fax or phone to ensure that appropriate information and clarity was given to ensure the best decisions were being made for the member's medical care

· De-escalated problematic customer concerns, maintaining calm, friendly demeanour.

· Investigated all complaint and appeals issues using knowledge base and personal experience to complete timely resolutions.

· Provided advice through work groups and committees in order to improve team, service and procedural standards.

· Prevented compliance concerns by researching discrepancies and taking corrective actions.

· Cultivated impactful relationships with members and providers that drove business development by delivering product knowledge.

· Created and implemented process improvements to reduce workloads and bolster job efficiency.

· Delivered fast, friendly and knowledgeable service for routine questions and service complaints.

· Worked independently on a strict timeframe

Triage Coordinator for Medicare Services-Part D

Aetna Inc., a CVS Company - Blue Ball, PA

July 2016 to December 2018

· Reviewed all incoming appeal requests received for the day from the various intake methods for priority, requester, and determination of valid part d drug

· Checked the appropriate systems for any Part D drug denials, reimbursements, and coverage determinations denials

· Rerouted to appropriate area for processing- possible (commercial member request, commercial Rx group member, MA-Only plan member, or possible HIPAA violation requests

· Researched any issues in reference to possible Out of Compliance requests, IRE request, IRE decision, ALJ and MAC notice and routed to the appropriate department for resolution.

· Triaged incomplete components of complaints/appeals to appropriate subject matter expert within another business unit(s) for resolution response content to be included in final resolution response. · Department lead for quarterly newsletter and Moral/Activities Committee

Complaint and Appeal Analyst

Part D Medicare Aetna Inc., a CVS Company - Blue Bell, FL October 2014 to May 2016

· Coordinated effective resolution of member or provider/practitioner appeals

· Managed to resolution complaint/appeal scenarios for prescription drug products, which may contain multiple issues and, may require coordination of responses from multiple business units.

· Ensured timely, customer focused response to complaints/appeals.

· Identified trends and emerging issues and report and recommend solutions

· Identified and researched all components within member or provider complaints/appeals for all products and services

· Coordinated of all components of complaints/appeals including final communication to member/provider for final resolution and closure

· Assured complaint/appeals were handled within established timeframe to meet company and regulatory requirements

· Identified trends or emerging issues and gave input on potential solutions thorough knowledge of member and provider appeal policies

· Developed strong analytical skills focusing on accuracy and attention to detail

· Perfected excellent verbal and written communication skills

· Met demands of a high paced environment with tight turnaround times.

· Made appropriate decisions based upon Aetna's current policies/guidelines

Member Services Representative

Medicare Serv / Aetna Inc., a CVS Company - Blue Bell, PA

October 2012 to October 2014

· Became proficient in healthcare terminology and dynamics of the healthcare profession.

· Provided integrated health information to drive informed decision-making.

· Managed multiple priorities.

· Aligned work to strategy using the Aetna Way values.

· Embraced change.

· Demonstrated cross-cultural sensitivity.

· Understood the members point of view.

· Collaborated with associates to create value for constituents.

· Resolved conflicts while maintaining good member relationships.

· Managed integrated service delivery.

· Department Lead for Blue Bell Medicare Member Services Operations Employee Engagement Committee.

· Culture Advocate.

· Assisted with the planning and implementation of quarter employee celebrations.

· Focus group member that assisted in the implementation of a Claims Helpdesk for Medicare Member Services Operations.

Collections Representative

WELLS FARGO BANK - Chester, PA

January 2010 to September 2011

· Collected on overdrawn checking and savings accounts for Wachovia and Wells Fargo Bank customers.

· Handled transferring of funds; credit and debit transactions and checks from customers to pay on overdrawn accounts.

· Data Entry.

· Organized team building events for my department.

· Team Lead for United Way Fundraising Campaign for my department.

· Team member of Social Responsibility Committee for Wells Fargo ODCR Chester County Division.

Customer Service Representative

SRC an AETNA COMPANY - Columbia, SC

October 2007 to May 2008

· Enrolled members in health insurance benefit.

· Answered any questions or concerns dealing with insurance benefits and policies. · Data Entry.

Education

Bachelor of Science in Healthcare Administration

South University - Remote

May 2022 to Present

Skills

•Independent Worker

•Multitask effectively and efficiently

•Critical Thinker

•Innovative problem-solver who can generate workable solutions and resolve complaints

•Hard working, focused and highly motivated professional

•Excellent communication (listens attentively, speaks effectively, writes clearly and concisely)

•Researching and Organizing with a high degree of detail orientation

•Data Entry

•Computer Skills in Microsoft Word

•Outlook

•Excel

•PowerPoint

•Medical terminology

•Phone etiquette

•Customer service

•English

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