Amanda Lemieux
Blue Ash,OH
Summary
Accomplished Grievance & Appeals Auditor with a proven track record at Elevance Health, demonstrating exceptional analytical problem-solving and team collaboration skills. Recognized for enhancing compliance processes and achieving a 100% customer satisfaction score, showcasing an adeptness in audit programs and a commitment to excellence.
Overview
16
16
years of professional experience
Work History
Grievance & Appeals Auditor I
Elevance Health
Mason, OH
04.2023 - Current
- Evaluates out-of-compliance (OOC) Part B and C pre-service cases to uncover compliance issues and propose enhancements to existing processes.
- Participates in internal and external audits:
- Reviews cases to ensure compliance with federal and state regulations, enterprise policies, and accreditation standards.
- Reviews case documentation to assess whether appropriate system entries have been made, and that the step-by-step process is sufficient to mitigate the risk associated with regulatory reviews, accreditation reviews, and potential litigation.
- Compiles the necessary documentation and case files.
- Assist in presenting sample cases.
- Assist management in process improvement strategies to achieve business objectives.
- Prepare audit findings and recommendations for G&A associates and management every month.
- Assist in identifying trends and developing training materials.
- Assist in testing in UAT, and provide feedback about the results.
- Help to clarify concepts for others through discussion, screen sharing, screenshots, and video (if necessary)
- Independently pulls daily reports, which allows me to resolve errors and identify cases at risk of going OOC
- Have received managerial commendation for preventing issues on two separate occasions
- Identified a wording discrepancy in Initial Denial Notices [IDNs] that may lead to miscommunication and member/provider abrasion
- Reached out to manager with concerns
- Manager contacted Compliance, who confirmed that the wording was misleading and led a discussion on how to resolve
- A change will be made to IDNs in 2025 to remove/replace the verbiage
- Reviewed appeals cases to ensure compliance with operational and CMS regulation standards.
Grievance & Appeals Analyst I
Elevance Health
Mason, OH
12.2021 - 04.2023
- As a Part B/C front-end analyst: reviewed, analyzed, and processed non-complex appeals in accordance with external accreditation and regulatory requirements, internal policies and claims events requiring adaptation of written response in clear, understandable language
- Utilized guidelines and review tools to conduct extensive research and analyze the appeal issue(s) and pertinent medical records to either approve or summarize and route to nursing and/or medical staff for review
- As a Part B/C Closure & Effectuations analyst: reviewed, cross-checked information, released decision letters, and closed appeals that have had a decision rendered
- Contacted provider offices and PMGs to obtain information needed to close cases
- High productivity and accuracy rate
- Selected by manager to assist in root cause analysis, analyzing out-of-compliance cases to determine root cause and suggest process improvements
- Identified case errors and coached analysts to reduce future errors
- Assisted in reviewing and updating training materials for accuracy and clarity and identifying processes needing additional training
- Received 'Exceeded Expectations' on most recent performance review
Customer Care Representative
Elevance Health
Mason, OH
08.2020 - 12.2021
- Researched and verified information on customer insurance claims and resolved anomalies or errors for all branches of Anthem
- Addressed and resolved customer inquiries and complaints
- Excelled at researching hidden details and taking additional steps to find critical data
- Key player in special inventory projects researching different requests from providers and members, researching claims authorizations, and verifying critical information
- Verified that company branding and documentation matches client
- Talked with customer service representatives at multiple billing offices to verify coding and to ensure medical history accuracy and prevent pricing errors
Shift Leader / Guest Services Representative
Nothing Bundt Cakes
Mason, OH
08.2017 - 08.2020
- Promoted to leadership/administrative role after one year of employment
- Responsibilities included communicating with guests, resolving issues and complaints, entering orders into computer system, taking payment information, processing payments, and stocking the till
- Tracked lost or missing orders, resolved complaints
- Contributed to 100% customer satisfaction scores for several months
- Assisted customers in choosing cakes, party favors, and balloons
- Upsold products as appropriate for occasion, age groups, and to meet customer needs
- Assumed additional tasks as needed
- Awarded 'Guest Service Representative of the Month' for four consecutive months, based on customer feedback
- Cut printing costs and simplified printing for custom message and quote cards by creating templates
Deli Assistant / Sales Clerk
Servatii Bakery & Deli
Montgomery, OH
09.2008 - 01.2010
- Promoted to add Deli responsibilities
- Prepared food orders, maintained inventory, and restocked when needed
- Marked and disposed food, maintained and closed deli
- Maintained attractiveness of food displays
- Entrusted with defusing sensitive situations with difficult customers
Education
MASTER OF SCIENCE - Healthcare Fraud, Waste, and Abuse
University of New Haven
New Haven, CT01.2025
BACHELOR OF ARTS - Psychology
University of Massachusetts Lowell
Lowell, MA12.2018
ASSOCIATE OF ARTS - Psychology and Sociology
Sinclair Community College
Dayton, OH12.2012
Skills
- Windows
- Microsoft Office
- Compass
- Clarity
- Facets
- Medisys
- MACESS
- DocHub
- MARx
- Transcentra
- BDS
- Member360
- Virtual Appeals Manager (VAM)
- PEGA NextGen
- Audit plan development
- Analytical problem solving
- Time management
- Audit programs and processes
- Decision-making
- Report generation
- Team collaboration
Volunteer Experience
- Usher, Aronoff Center for the Arts, Cincinnati, OH, 01/01/12, 01/01/23
- Usher, Cincinnati Playhouse in the Park, Cincinnati, OH, 09/01/15, 01/01/23
Timeline
Grievance & Appeals Auditor I
Elevance Health
04.2023 - Current
Grievance & Appeals Analyst I
Elevance Health
12.2021 - 04.2023
Customer Care Representative
Elevance Health
08.2020 - 12.2021
Shift Leader / Guest Services Representative
Nothing Bundt Cakes
08.2017 - 08.2020
Deli Assistant / Sales Clerk
Servatii Bakery & Deli
09.2008 - 01.2010
MASTER OF SCIENCE - Healthcare Fraud, Waste, and Abuse
University of New Haven
BACHELOR OF ARTS - Psychology
University of Massachusetts Lowell
ASSOCIATE OF ARTS - Psychology and Sociology
Sinclair Community College