Heather Ducarme
Scottdale
Summary
Dynamic Senior Grievance Analyst at Aetna Medicare, adept at resolving complex complaints and ensuring compliance with CMS regulations. Proven expertise in grievance analysis and data reporting, coupled with strong verbal communication skills. Recognized for enhancing member satisfaction through effective case management and training initiatives.
Overview
20
20
years of professional experience
Work History
SENIOR GRIEVANCE ANALYST
Aetna Medicare health plan
Remote
07.2022 - 07.2025
- Investigated and resolved complex complaints related to enrollment, claims, payment disputes and appeals.
- Review clinical and medical documentation using nationally recognized criteria to ensure compliance.
- Drafted accurate, clear client-facing communications and determination letters.
- Conducted outreach to members, providers, attorneys and other stake-holders to provide case status updates and education.
- Analyzed grievance and appeal data then prepared reports for leadership.
- Ensure accuracy and professionalism in all interactions to support member satisfaction and compliance.
- Experience with the Grievance Support Team (GST) to initiate case reviews, training and mentoring.
- Processed Medicare-specific cases efficiently.
- Conducted grievance reviews for member misrepresentation, focusing on enrollment issues through brokers, Medicare, and online services.
- Evaluated instances of erroneous or fraudulent enrollment into plans, maintaining compliance with CMS regulations.
SHEET METAL PRODUCTION WORKER
DUCTMATE INDUSTRIES
Monongahela
10.2021 - 04.2022
- Operated machinery to assemble ventilation products efficiently and safely.
- Inspected finished products for quality control and adherence to specifications.
- Collaborated with team members to optimize production workflows and reduce downtime.
- Followed detailed work instructions to meet production schedules accurately and consistently.
CERTIFIED MEDICAL ASSISTANT
Urology Associates of Beaver
Beaver
11.2009 - 09.2013
- Assisted physician with daily office procedures such as cystoscopy, vasectomy, and prostate biopsies.
- Assisted physicians and nurses with patient exams, including taking vital signs, preparing exam rooms, and updating medical records.
- Skilled in performing catheterization and delivering injections, immunizations, and medications as directed by physicians.
- Performing medication authorizations and ordering of patient medications to be administered in the office.
- Collected and processed laboratory specimens for testing.
- Supported office operations by handling phone inquiries and patient communication.
CERTIFIED MEDICAL ASSISTANT, PEDIATRICS
Childrens Community Pediatrics - Bass Wolfson
Cranberry Twp
03.2006 - 11.2009
- Scheduled appointments and managed patient flow efficiently throughout the day.
- Administered immunizations and collected laboratory specimens as required.
- Handled billing inquiries and processed insurance claims for pediatric services.
- Ordered medical supplies, equipment, and medications as needed.
- Maintained confidentiality of all patient information according to HIPAA regulations.
- Obtained authorization from insurance companies for requested services or medications.
- Assisted pediatricians in conducting routine examinations and assessments.
- Proficient in Epic and Epicare electronic medical records.
MEDICAL ASSISTANT-FRONT/BACK
Dr. Randy Shemer DO-Internal Medicine
Monaca
06.2005 - 03.2006
- Assisted physicians with patient care by taking vital signs, patient histories and preparing patients for examinations.
- Administered injections, medications and treatments as directed by the physician.
- Proficient in Medisoft and Microsoft Word.
- Adhered to HIPAA regulations regarding safeguarding confidential patient information at all times.
- Answered phones, scheduled appointments and managed patient flow while greeting visitors in a professional manner.
- Handled insurance verification and processed billing information effectively.
Education
Post-secondary education, no degree or certificate - Nursing
Community College of Allegheny County
02.2015
Post-secondary education, no degree or certificate - Nursing
Community College of Beaver County
06.2013
Vocational/Technical Certificate - Medical Assistant
DCI Career Institute
Monaca, PA05-2005
High School Diploma -
Blackhawk High School
Beaver Falls, PA06.2004
Skills
- Grievance & Appeals Resolution (Medicare/Healthcare)
- Case Review & Compliance Documentation
- Grievance analysis
- Data reporting
- Case management
- Customer relationship management
- Training and mentoring
- Microsoft Office (Word, Excel, Outlook)
- Verbal and written communication
- Experience in HIPAA adherence
References
References are available upon request
Timeline
SENIOR GRIEVANCE ANALYST
Aetna Medicare health plan
07.2022 - 07.2025
SHEET METAL PRODUCTION WORKER
DUCTMATE INDUSTRIES
10.2021 - 04.2022
CERTIFIED MEDICAL ASSISTANT
Urology Associates of Beaver
11.2009 - 09.2013
CERTIFIED MEDICAL ASSISTANT, PEDIATRICS
Childrens Community Pediatrics - Bass Wolfson
03.2006 - 11.2009
MEDICAL ASSISTANT-FRONT/BACK
Dr. Randy Shemer DO-Internal Medicine
06.2005 - 03.2006
Post-secondary education, no degree or certificate - Nursing
Community College of Allegheny County
Post-secondary education, no degree or certificate - Nursing
Community College of Beaver County
Vocational/Technical Certificate - Medical Assistant
DCI Career Institute
High School Diploma -
Blackhawk High School