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Shanequa
shanequaknight@yahoo.com
904-707-5628
Jacksonville, FL 32099
Grievance Complaint/Appeal Analyst
7 years experience
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Summary

Experience
Grievance Complaint/Appeal Analyst
Medical Devices
Aug 2020 - Aug 2020
Determines the root of an issue/complaint
  • Case management
  • Inventory Management
  • Handles expedited appeals/complaints with attention to deadlines.
  • Rely on company policies and state and federal laws to determine whether a claim should be paid or grievance valid. Attention on compliance.
  • Critical thinking and complex resolution skills.
  • Fairly evaluates rebuttals at the first level review, using documented workflows/policies.
  • Coordinate effective resolution of member or provider/practitioner appeals.
  • Handles/reviews Medical and RX claims/benefits.
  • Uses expert letter writing skills, spelling, grammar, punctuation, inclusion of appropriate letter content, and appropriate state/federal regulatory language when required.
  • Resolves provider and member complaints.
  • Assist with written/verbal medical and pharmacy appeals for members and providers.
  • Conducts a thorough investigation and often must contact more than one party to resolve the dispute.
  • Drafts a letter to the complainant reiterating the incidents reported and the responses obtained.
  • Provides if corrective action was taken as a result of incorrect If corrective action was taken as a result of the complaint.
  • Identifies trends and emerging issues and reports on and gives input on potential solutions.
  • Uses expert skills and knowledge at researching standard plan design, certification of coverage and potential contractual deviations to determine the accuracy and appropriateness of a benefit/administrative denial. Can review a clinical determination and understand rationale for decision.
Compliance Inventory Management
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RETAIL REPRESENTATIVE
Oct 2019 - Feb 2020
  • Greet and direct customers
  • Provide accurate information (e.g. product features, pricing, and after-sales services)
  • Answer customers' questions about specific products/services
  • Conduct price and feature comparisons to facilitate purchasing
  • Cross-sell products
  • Ensure racks are fully stocked
  • Manage returns of merchandise
Sales
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Medical HEALTH CONCEIRGE
Medical Devices
Nov 2014 - Oct 2018
(traditional)
  • Answers questions and resolves issues as a "single-point-of-contact" based on phone calls, letters and Webchat from brokers, marketing plan sponsors, members, and providers.
  • Handles call escalations.
  • Provides coaching to other teammates.
Traditional Scala
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Non-cloudteam Skill
Education
DATE-FEBUARY
UNIVERSITY OF PHOENIX 2019
Skills
Scala
2018
3
Traditional
2018
3
Compliance
2020
1
Inventory Management
2020
1
Sales
2020
1