Appeals & Grievances Claims Resolution

Crystal M. Dailey

***** ****** **, *****, ** ****4

225-***-**** ****************@*****.***

Professional Summary

Results-driven and detail-oriented healthcare professional with over 10 years of experience in managed healthcare, specializing in appeals and grievances, claims processing, fraud investigation, and provider relations. Adept at analyzing complex cases, resolving disputes, and ensuring compliance with Medicaid and federal healthcare regulations. Strong communicator with expertise in medical coding (CPT, ICD, HCPCS), COB insurance verification, authorizations, and process improvement. Recognized for enhancing efficiency, reducing claim errors, and delivering exceptional customer service.

Core Skills & Competencies

Appeals & Grievances Case Management

Pre/Post Service, Medicare, Medicaid, Dental and Behavioral Health Appeals

Claims Research and Resolution

Healthcare Claims Processing & Fraud Investigation

Medicaid & Federal Healthcare Compliance

Insurance Verification & Provider Relations

Medical Terminology & Coding (CPT, ICD, HCPCS)

Process Improvement & Workflow Optimization

Advanced Research & Problem-Solving

Quality of Care, Quality of Service and Transportation Grievances

Professional Experience:

Centene-Louisiana Health Care Connection

Appeal and Grievances Coord II & Independent Reviews (August 2024-Current)

Review and process member and provider appeal within federal, state and organizational regulations and policies and procedures.

Review claim grievance/appeal for reconsideration and either approve/deny based on determination level or prepare for medical review presentation. Prepare cases for medical review as necessary.

Review and determine if claim grievance includes a potential quality or access issue.

Independent Reviews

Claims Projects

Collaborate with subject matter experts within the organization to obtain benefit and/or clinical opinions/interpretations of complex cases.

Monitor and track appeal turnaround times to ensure compliance with CMS and NCQA standards.

Serve as liaison between members, provider regulatory agencies and internal staff. Correspond with key individuals regarding grievance and appeal decisions.

UnitedHealthcare – Optum

Triage Investigator Recovery Resolution Analyst (July 2022 – May 2024)

Conducted triage of provider fraud and payment integrity cases, ensuring proper documentation and compliance with SOPs.

Rejected incomplete or non-compliant tips, optimizing workflow efficiency.

Communicated with internal/external partners to expedite case resolution.

Managed ORS mailbox, reviewing and responding to inquiries effectively.

Researched provider demographics, claim processing, and billing practices to identify discrepancies and recover funds.

UnitedHealthcare

Appeals & Grievances Resolving Analyst II (July 2016 – July 2022)

Analyzed and resolved member and provider appeals, ensuring fair and timely resolution.

Process URGENT appeal requests in allotted time frame.

Conducted medical record reviews and submitted cases for reconsideration and medical review.

Facilitated Grievance and Appeals 2nd Level Committee Panel meetings, providing subject matter expertise.

Collaborate with Medical Directors, Legal, and clinical teams to review cases.

Reviewed and resolved provider/member grievances.

Create resolution letters for members and providers.

Create and Update authorization for preservice or post service.

Claims research for adjustments and billing issues.

Processed quality-of-care grievances/complaints and coordinated claim adjustments.

Served as backup Subject Matter Expert (SME), mentoring new analysts.

Key Achievements:

Reduced appeal resolution time by 30% through workflow optimization.

Lead training initiatives, improving team efficiency and compliance rates.

Blue Cross Blue Shield of Louisiana

Account Advisor – Federal Employee Program (August 2014 – 2016)

Provided benefits guidance to federal employees, resolving claims and billing inquiries.

Assisted with case management and claim adjustments, ensuring accurate claim payments.

Analyzed and processed healthcare claims for accuracy and completeness.

Maintained compliance with HIPAA guidelines and federal healthcare regulations.

Cox Communications

Account Service Representative (Team Coach) (2010 – 2014)

Led a team in handling inbound/outbound calls, reconciling delinquent accounts.

Negotiated payment arrangements, processed account modifications, and identified fraudulent accounts.

Conducted team meetings to improve morale and performance.

Software & Technical Proficiency

Healthcare Systems: Facets, Macess, FEP Direct, Common Query Tool, PEGA, OMNI, ORS, PICTS, AMISYS, DRGs, CenPas, INAV, DOC360

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