Brittney Pierre
Hawthorne,CA
Summary
Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.
Overview
20
20
years of professional experience
1
1
Certification
Work History
Appeals and Grievance Coordinator
Health Net, Inc. / Centene
Woodland Hills, CA
11.2022 - Current
- Respond to written and verbal grievances, appeals, inquiries and disputes submitted by members
- Review, research, resolve and respond to various cases in accordance with guidelines established by all lines of business
- Review, evaluate and log all client appeals and grievances requests
- Determine eligibility and benefit status in reference to members outstanding claims and billing matters
- Outreach made to members to ensure the appropriate resolution for the appeal/grievance is achieved
- Accountable for appropriate review and determination in compliance with state and federal regulations with DMHC DHS, and CMS.
- Identify if a denied service or claim should be upheld or overturned and or consult with the companies Medical Director to assist in the final determination process
- Conduct thorough investigation of all members correspondence by analyzing all the issues involved and obtaining responses and information from internal and external entities
- Perform comprehensive research related to the facts and circumstances of a member complaint, to include appropriate classification as a grievance, appeal, or both, in accordance with regulatory requirements
- Follow-up with responsible departments and delegated entities to ensure compliance
- Responsible for making verbal contact with members authorized guardian during the research process to clarify the member's complaint
- Responsible for timely and complete documentation of an appeal and/ or grievance for accurate written documentation to members advising of an resolution within 30 calendar days of the initial complaint
- Prepare and mail written resolution letters to members
- Work directly with regulatory team to to ensure compliance and department processes are met with state regulators and stakeholders
- Serve as liaison between Healthcare departments, delegated entities, medical groups and network physicians to ensure timely resolution of cases
- Work closely with internal departments for resolution to provide educational benefits to members
- Prepare statement of positions for member requested state fair hearings
- Accompany the claimant during hearings with the administrative law judge to ensure proper resolutions on behalf of recurring denials
- Triage all compliants and distribute to appeals and grievances departments based on line of business
- Attend and adhere to all department trainings and visual testing
- Perform other tasks, etc., as needed.
Adminstrative Assistant/ Credentialing Specialist-Provider Data Specialist
Optum Care
02.2019 - 11.2022
- Submit credentialed provider submissions to several health plans
- Forecast and prepare providers for upcoming license renewals and facility site reviews
- Monitor incoming claims and inform patients on status of eligibility
- Research and investigate claim denials
- Review and prepare insurance claims to effectively insure that billing requirements are met
- Schedule and notify patients of appointments and denials
- Gather necessary information to assist patients with appeals process
- Work closely with health plans to help resolve claim issues in a timely matter
- Follow up daily with health plans and region to assure approved status for providers and patients
- Act as Liaison between providers and health plans when researching and investigating patient inquiries
- Verify insurance site keys for all provider submissions
- Pull service forms, CSUFs and PSFs from Apollo and Macess and execute all change, add and term requests
- Heavy use of Salesforce, Workday, and GE/ IDX when tracking submissions
- Upload and create daily reports
- Conduct Webx meetings with region to strategize and plan for all future provider projects and CAP
- Answer phone calls and direct to appropriate departments
- Correspond to all contacts via Microsoft office/ e-mail and Skype in a timely matter
- Research and tally the estimated time to load a PCP or Specialist to all health plans directories
- Update, upload and notate all assignments daily and store them to companies data base
- Adhere to providers monthly attestations for site reviews
- Plan all department activities and meetings
- Adhere to HIPAA regulations and confidentialities.
Administrative Assistant/ Receptionist
Fashion Nova
04.2017 - 02.2019
- Act as liaison between staff and clients
- Maintain files and receipts for monthly expense reports, arrange and book meetings/interviews assist with travel arrangements for CEO, models and guest
- Answer and direct high volume phone calls to appropriate personnel
- Order office supplies and keep count of weekly inventory
- Order office lunches for CEO and Models
- Check -in clothing samples and transport them over to our buying team
- Assist with special events and milestones for the company
- Create, maintain, and enter information into databases
- Set up and manage paper or electronic filing systems, recording information, updating paperwork, or maintaining documents, such as attendance records, correspondence, or other material
- Operate office equipment, such as fax machines, copiers, or phone systems and arrange for repairs when equipment malfunctions
- Maintain scheduling and event calendars
- Provide services to customers, such as order placement or account information
- Supervise other clerical staff and provide training and orientation to new staff
- Locate and attach appropriate files to incoming correspondence requiring replies.
Receptionist
Visionaire Lighting LLC
11.2010 - 04.2017
- Answered and transferred high volume calls to appropriate personnel
- Manage and maintain front desk/ lobby
- Greet guest entering establishment, determine nature and purpose of visit, and direct or escort them to specific destinations
- Created photocopies and able to perform essential multi-tasking duties
- Coordinate lunch and learn meetings
- Schedule corporate meetings via MS Office
- Prepare and ship out/ USPS/UPS/FedEx packages
- Send and receive fax, scan and upload files(PDF) to company directory
- Book conference room, and assisted company with all other clerical duties
- Data entry, MS Outlook, MS Word, MS Excel Time
- Management, Customer service ethics
- Excellent front point of contact and team player
- Purchase supplies for all departments scout employee personnel and conduct interviews.
Administrative Assistant/ Client Service/ Call Center Representative
Burke Williams Day Spa
01.2006 - 10.2010
- Booked and conducted all spa appointments
- Directed phone calls to requested departments
- Arranged spa parties, including serving and preparing lunches for all guest
- Opened and closed invoices for guest
- Initiated guest and employee relations, maintained customer e-mails and followed up with client complaints and inquires
- Maintain scheduling and event calendars
- Schedule and confirm appointments for clients, customers, or supervisors
- Make copies of correspondence or other printed material
- Conduct searches to find needed information, using such sources as the Internet
- Assist all departments with all various task.
Call Center Representative
Enterprise Car rental
06.2005 - 10.2006
- Booked car rentals for clients
- Counted and maintained fleet inventory
- Answered high volume phone calls
- On call for all communications/computer related issues or matters
- Resolve long term renters accounts and complaints
- Initiated roadside assistance to clients disabled in route
- Explain products or services and prices, and answer questions from customers.
Education
English - Medical Coding And Billing
California State University Dominguez Hills
Carson, CA02.2022
Skills
- Problem solver
- Multi-tasker
- Administrative Assistant
- Scheduling
- Receptionist
- Clerical
- Data Entry
- Filing
- Microsoft Office
- Microsoft Word
- Organizational Skills
- Outlook
- Billing
- English
- Medical Billing
- Medical Scheduling
- Office Management
- Insurance Verification
- ICD-10
- Medical Office Experience
- Medical Coding
- Medical Terminology
- Event Planning
- Medical Records Skills
- Excellent verbal communication skills
- Work well with others
- Ability to work under pressure
- Intermediate computer skills
- Flexible and able to adjust to the work environment
- Customer awareness
- Good work ethics
- Critical Thinking
- Coordination
- Monitoring
- Active Learning
- Negotiation
- Epic
- Schedule management
- Communication skills
- Management
- Time management
- Customer service
- Supervising experience
- Leadership
- HIPAA
- Salesforce
- Workday
- SharePoint
- Databases
- Research
- Clerical experience
- Office management
- Interviewing
- Procurement
- Problem-solving
- Multitasking skills
- Attention to detail
- Problem-solving abilities
- Listening skills
- Reliability
- Multitasking Abilities
- Excellent communication
- Critical thinking
- Organizational skills
- Team collaboration
- Adaptability and flexibility
- Decision-making
- Legal research
- Professionalism
Certification
Medical Billing Certification
Contact
Carson, CA
Contact
Hawthorne, CA 90250
Timeline
Appeals and Grievance Coordinator
Health Net, Inc. / Centene
11.2022 - Current
Adminstrative Assistant/ Credentialing Specialist-Provider Data Specialist
Optum Care
02.2019 - 11.2022
Administrative Assistant/ Receptionist
Fashion Nova
04.2017 - 02.2019
Receptionist
Visionaire Lighting LLC
11.2010 - 04.2017
Administrative Assistant/ Client Service/ Call Center Representative
Burke Williams Day Spa
01.2006 - 10.2010
Call Center Representative
Enterprise Car rental
06.2005 - 10.2006
English - Medical Coding And Billing
California State University Dominguez Hills