Patient Care Dispute Resolution

April Gray

********@*****.*** 727-***-**** Spring Hill, FL

SUMMARY

Seeking Provider Payment Appeal Analyst I role with 28 years of experience in claims operations and payment dispute resolution. Expertise in root cause analysis, reconsideration, and appeals processing, consistently achieving high-quality standards. Proven track record in resolving complex provider payment appeals and delivering accurate, timely resolutions in a fast-paced environment.

WORK EXPERIENCE

United Healthcare Remote

Senior Resolving Analyst Nov 2019 - Present

• Research and resolve written appeals submitted by members and providers, ensuring accurate categorization and comprehensive review.

• Obtain and assess additional documentation necessary for thorough case analysis, determining need for clinical evaluation.

• Render decisions on administrative appeals using fact-based judgment and complete documentation with appropriate templates.

• Consistently achieve over 100% in quality audits, corporate audits, and quality standards, ensuring timely and accurate resolution of cases.

Claims Associate Nov 2003 - Nov 2019

• Processed medical claims within the Internal Resolution Unit, ensuring compliance with departmental standards, corporate policies, and governmental regulations.

• Achieved over 100% of production goals for 11 out of 12 months and maintained 100% quality in claim processing for 10 out of 12 months.

• Selected by leadership to process high-profile specialty groups and to serve as a Beta tester for the new system, Wand Work Space.

• Trained colleagues on specialty group processing and endorsed for telecommuter status due to high performance and excellent work ethics.

Amscot Port Richey, FL

Assistant Manager Tax Service Oct 2010 - 2013

• Managed customer interactions, including greeting clients and handling phone inquiries, while preparing consolidated company federal, individual, and multi-state tax returns.

• Supervised and scheduled staff, providing training on tax issues and new tax laws to ensure compliance and enhance team expertise.

NPCMC New Port Richey, FL

Front Office Staff Mar 1997 - Nov 2003

• Managed patient communications through phone and in-person interactions, ensuring efficient scheduling and appointment coordination.

• Utilized proficiency in Microsoft Office and medical data programs to maintain organized and accessible patient records.

• Coordinated billing and office operations, effectively balancing multiple projects to meet deadlines and uphold service standards.

Morton Plant Mease Dunedin, FL

Patient Care Tech/Unit Secretary Mar 1997 - Nov 1998

• Monitored and documented patient vital signs, providing critical support in pre- and post-operative care for heart surgery patients.

• Managed and accurately entered physician orders, coordinating scheduling for medical procedures. EDUCATION

James H Groves

Diploma

Stanton, DE

May 1985

Morton Plant Mease Hospital

Certificate, Certified Nursing Assistant/Patient Care Tech/ HIPAA Certification Dunedin, FL

1997

United Healthcare

Certificate, HIPAA Certification

Oldsmar, FL

2003

PHSC

College, Medical Terminology

Spring Hill, FL

2019

SKILLS

Word • Excel • PowerPoint • Problem Solving • Communication Skills • Analytical Skills • Collaboration • Attention To Detail

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