Dynamic Senior Complaint and Appeals Coordinator at Aetna/CVS Health with proven expertise in HIPAA compliance and effective communication. Spearheaded training initiatives for new hires and led projects that streamlined appeal processes, enhancing operational efficiency. Recognized for critical thinking and problem-solving abilities, driving successful outcomes in complex appeal cases.
Responsibilities and Achievement
Trained class of 17 new hires in their soft landing for research.
Trained class of 7 new hires in their soft landing for research.
Assist associate managers with One on Ones.
Performed coaching calls with coordinators.
Review and decision appeals.
Cross trained in all areas of appeals.
Proficient in Launch, RFD, Dismissals, Vacates, Research, Upholds, and Effectuations.
Lead Senior for the Upholds Queue.
Lead Senior for all auto forward inventory.
Run daily reports.
Track daily uphold and auto forward inventory to ensure all appeals stay in compliance.
Trained a multitude of staff members to write narratives, create, IRE Packets, and submit upholds and partials to MAXIMUS via the QIC Portal.
First senior to be released independently to review and decision upholds.
First senior to be fully trained on how to write narratives and create packets and submit cases to the the Maximus Portal.
Worked with the Data Science Team on the EPDB PAR Status Check in Case Launch Feature of MNP Case Preparation Tool project.
Currently assisting with the 1668 Bot Initiative Project that streamlines creating a BOT to create the narrative/packet and submit the appeal to MAXIMUS via the QIC Portal.
Launching member and MNP Appeals.
Researching and decisioning member and MNP Appeals.
Mentored launch coordinators.
Became the Dental SME for researching appeals.