Aneatra Harvey
Rancho Cordova,CA
Summary
Grievances and Appeals Analyst at Elevance Health with expertise in managing appeals processes and resolving conflicts. Demonstrated ability to analyze complex claims while ensuring compliance with regulatory standards. Proficient in enhancing workflow efficiency through strong analytical skills and effective communication with stakeholders. Dedicated to upholding ethical standards and driving continuous improvement initiatives.
Overview
18
18
years of professional experience
Work History
Grievances and Appeals Analyst
Elevance Health (Anthem)
06.2023 - Current
- Reviewed, analyzed, and processed non-complex grievances and appeals in strict accordance with external accreditation and regulatory requirements, as well as internal policies, ensuring clear and understandable written responses.
- Utilized established guidelines and review tools to conduct thorough research and analysis of grievance and appeal issues, including relevant claims and medical records, to approve or refer to nursing and/or medical staff for further review.
- Maintained strict adherence to department guidelines and tools to ensure compliance with accreditation and regulatory standards, including file review components of URAC and NCQA accreditations.
- Analyzed and rendered determinations on assigned non-complex grievance and appeal issues, preparing written communication documents to convey decisions effectively.
- Acted as a liaison between grievances & appeals, medical management, legal, service operations, and other internal departments as needed.
- Excluded from conducting utilization or medical management reviews requiring clinical interpretation, focusing solely on non-complex grievance and appeal processes.
Program Technician II
State of California – Covered California
12.2020 - 06.2023
- Responded to customer service contacts via the ACD system, providing information and guidance on health plan options.
- Conducted needs assessments for consumers, facilitating enrollment into plans via the HBEX (Health Benefit Exchange) and referred consumers to Medi-Cal Programs as needed.
- Delivered comprehensive information on health and dental insurance, including monthly premiums, to assist consumers in making informed decisions.
- Assisted consumers with enrollment inquiries and updated applications as necessary to ensure accuracy.
- Provided detailed benefit information to help consumers understand their coverage.
- Triaged cases to the next level of support when additional research or corrections were required for resolution.
Shield Concierge Claims Representative
Blue Shield of California
10.2017 - 11.2020
- Analyzed provider and commercial account contracts, ensuring compliance with relevant state and Federal laws.
- Facilitated meetings by providing agendas and researching statistical data from surveys to support informed decision-making.
- Resolved claim status inquiries, processed and adjusted claims as necessary, ensuring accuracy and adherence to protocols.
- Triaged cases to appropriate departments, meticulously documenting case statuses for streamlined resolution.
- Demonstrated proactive dispute resolution skills, resolving conflicts before escalation to Appeals and Grievances.
- Engaged members proactively, educating them on wellness plan options and promoting health literacy.
- Expanded proficiency in medical terminology, enhancing effectiveness in resolving member inquiries.
- Triaged complex cases to Registered Nurses when necessary, ensuring appropriate handling beyond standard authority.
TA Client Service Representative
Franklin Templeton Investments
11.2016 - 10.2017
- Responsibly managed routine inbound calls, adeptly addressing customer concerns and providing effective solutions to meet their needs.
- Handled complex financial inquiries related to funds, retirement plans, and market performance, ensuring accurate and comprehensive responses.
- Conducted intricate research for shareholders and financial advisors, delivering valuable insights and recommendations as required.
- Utilized multiple systems proficiently to gather and provide accurate market data to shareholders and financial advisors, enhancing decision-making processes.
- Processed high-value redemptions, purchases, and fund exchanges for shareholders and advisors, demonstrating meticulous attention to detail and adherence to procedures.
Senior Patient Account Representative
Dignity Health/Optum 360
02.2015 - 11.2016
- Extensive expertise in healthcare insurance systems, encompassing HMO, POS, and PPO plans.
- Proficient in verifying insurance eligibility and securing necessary authorizations for medical procedures.
- Well-versed in medical coding, including ICD-9 and CPT coding systems.
- Exceptional problem-solving skills and resourcefulness in addressing patient concerns and resolving issues.
- Proactive in obtaining verifications and following up on pending authorizations to ensure timely processing.
- Skilled negotiator with a track record of advising on and recovering overdue or incorrect claims payments.
Customer Service Rep II
Health Net
11.2007 - 02.2015
- Managed health plan data using automated systems, ensuring adherence to production and quality standards.
- Liaised with internal staff and external customers to verify information, facilitating efficient processing.
- Maintained strict confidentiality of medical records, adhering to privacy regulations.
- Handled 50-65 daily calls from healthcare providers and insurance customers, resolving inquiries promptly.
- Organized and maintained patient medical and financial records efficiently.
- Processed research requests and released information in compliance with regulations.
- Addressed insurance concerns and coordinated services to optimize patient care.
Education
Bachelor of Arts - Sociology
Sacramento State
Sacramento, CA05-2025
Skills
- Analytical/Research Skills
- Medical Claims
- Appeals Process Management
- Conflict Resolution
- HIPPA Compliance
- Workflow Coordination
- Well versed in Health Ins
- Contract Analysis
- Resilient and Agile
- Data analysis
- Communication skills
- Conflict resolution
- Research skills
- Policy interpretation
- Case evaluation
- Verbal and written communication
- Interpersonal communication
- Examine reports
- Continuous improvement
- Insurance policy coverage expertise
- Evaluation
- Professionalism
- Ethical standards
- Written communication
- Self motivation
- Computer skills
References
Available Upon Request
Timeline
Grievances and Appeals Analyst
Elevance Health (Anthem)
06.2023 - Current
Program Technician II
State of California – Covered California
12.2020 - 06.2023
Shield Concierge Claims Representative
Blue Shield of California
10.2017 - 11.2020
TA Client Service Representative
Franklin Templeton Investments
11.2016 - 10.2017
Senior Patient Account Representative
Dignity Health/Optum 360
02.2015 - 11.2016
Customer Service Rep II
Health Net
11.2007 - 02.2015
Bachelor of Arts - Sociology
Sacramento State
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