Member services lead analyst Resume

SUMMARY:

EXPERIENCE:

Member services lead analyst

Confidential

Responsibilities:

Medicare Regulatory Analyst

Confidential

Responsibilities:

Strong Knowledge of CMS Appeal and Grievance Regulations
Trained Team Members on Medicare Advantage Appeals and Grievance Processes
Key Player in raising Medicare Advantage Star rating
Communication of Resolutions, Grievance and Appeal Rights, to Members
Auditing and Analysis of Grievance Trend Reports for Compliance and Performance Improvement
Oversight, Analysis and Resolution of Grievances for Quality of Care, Quality of Service, Medical Necessity, and FWA
Reviewing and Resolving Member Complaints
Acted as a Resource for Complex Appeal and Complaint Issues
Oversight of Grievance Processing by Member Services to Ensure Compliance with Compliance Standards, Policies, and Procedures
Oversight of Internal Teams on Compliance Processes
Built Relationships with Internal and External Stakeholders to Reduce Grievances and Appeals
Oversight of Appeal and Grievance cases to ensure meeting of CMS Requirements
Developed Process Improvements to reduce Turnaround Times
Tracking of Grievances and Appeals in Company Databases
Pre - and Post-Audit P&P Development and Updates

Benefit Advisor

Confidential

Responsibilities:

Compliant Enrollments for Transitioning Groups to HMO and PPO Medicare Advantage Plans
MAPD Team Resource Leader, Trained Agents on how to avoid Agent Grievances
Compliance Meetings with Management
Provided Direction on how to contact Carriers for Appeals and Escalations
Prescription Profiles and Provider Searches for Transitioning Group Clients
Communication Directly with Group Client Benefit Departments
Large and Small Group Account Transition Service. Clients included OPERS, IBM, GE, and Schlumberger
Top 5% Agent in Medicare Plan Sales for the 2016 AEP
Consultative Selling of Medicare Plans
Worked with Team to provide consistent up to date Compliance Advice to Team, Team Lead