CHERESE BLACKWELL
NEW YORK LIFE
Carnegie,USA
13
years of professional experience
Results-driven healthcare administration and claims professional with 10+ years of experience in short-term disability, Medicare complaints and appeals, healthcare operations, utilization management, and customer service. Experienced in managing high-volume caseloads, researching complex claims and appeals, interpreting medical and billing information, and making accurate, timely determinations in accordance with regulatory and organizational requirements. Recognized for sound judgment, exceptional communication, quality documentation, team coaching, and process improvement.
Work History
Integrated Short-Term Disability Claim Manager
2 Years 5 Months- Manage integrated absence cases involving Short-Term Disability (STD) and FMLA, providing service excellence to group benefits customers.
- Review cases, verify eligibility, evaluate medical information, apply contractual provisions, and make timely claim and leave determinations in accordance with legal and compliance requirements.
- Manage ongoing claims, including extensions and review of additional medical information, while ensuring accurate and timely benefit payments.
- Communicate with claimants, employers, physicians, and medical professionals to obtain information and resolve complex case issues.
- Maintain detailed case documentation and meet established service, processing, and performance standards.
- Partner with clients and Vocational Rehabilitation Counselors to facilitate full or modified return-to-work strategies.
Short-Term Disability Claim Manager
3 Years 9 Months- Managed an average caseload of 120–180 short-term disability claims, making eligibility, benefit, approval, denial, continuation, and closure determinations.
- Conducted comprehensive initial and ongoing claim reviews to ensure accurate, timely, and compliant benefit decisions.
- Collaborated with claimants, employers, physicians, and other stakeholders to obtain and evaluate information required for claim management.
- Resolved complex telephone and written inquiries involving eligibility, benefits, claim status, approvals, denials, continuations, and closures.
- Applied organizational policies, ERISA requirements, and applicable regulatory standards while maintaining high-quality documentation.
- Developed return-to-work strategies with clients and Vocational Rehabilitation Counselors and prioritized competing deadlines in a high-volume environment.
Senior Medicare Complaint & Appeal Analyst
1 Year 4 Months- Reviewed and resolved complex Medicare complaints and appeals while meeting regulatory and departmental turnaround requirements.
- Managed escalated member and provider cases and collaborated with cross-functional teams to achieve timely resolutions.
- Coached new analysts on case handling, research, processes, and complex issues.
- Analyzed inventory trends and supported initiatives designed to reduce outstanding case volume and improve workflow.
- Supported Medicare audit preparation by reviewing and validating audit universe data for accuracy, completeness, and compliance.
Medicare Complaint & Appeal Analyst
1 Year 8 Months- Investigated Medicare Part C member and provider complaints and appeals through comprehensive research and case analysis.
- Validated claims payments, member eligibility, billing status, and claims-processing logic before initiating appeal determinations.
- Applied ICD-9, ICD-10, CPT coding, and Medicare Chapter Guidance to research and evaluate healthcare claims.
- Researched Plan Sponsor fiduciary responsibility and prepared supporting documentation for denial determinations.
- Summarized case findings and communicated supporting information to Plan Sponsor contacts.
Medicare Grievance & Appeal Coordinator
1 Year 9 Months- Investigated Medicare Parts C and D complaints, identified root causes, and determined appropriate resolutions.
- Served as a primary contact for executive-level complaints and appeals, including matters involving Departments of Insurance, Departments of Health, and Attorneys General.
- Managed member and provider cases while ensuring accurate documentation and timely resolution.
- Identified recurring trends and emerging issues and communicated findings to leadership to support process improvements and backlog reduction.
Clinical Service Representative
1 Year- Created and maintained utilization management cases for surgeries, durable medical equipment, private-duty nursing, home health, nutritional supplements, and acute inpatient stays.
- Reviewed prior authorization documentation and routed cases to appropriate clinical staff according to departmental policies.
- Verified CPT codes and case information and communicated with members and providers regarding authorization-related questions.
- Consistently exceeded a 60-case daily production target while maintaining a 98% quality rating.
Engagement Specialist
8 Months- Conducted high-volume member outreach to promote preventive screenings and improve engagement with recommended healthcare services.
- Scheduled physician appointments and researched in-network providers based on member needs and plan coverage.
- Maintained HIPAA privacy and confidentiality requirements and referred members to appropriate case management resources.
Education
Bachelor of Arts - Criminal Justice
Skills
Short-Term Disability & Leave Management
Medicare Complaints & Appeals
Claims Research & Adjudication
Eligibility & Benefit Determinations
ERISA & Regulatory Compliance
Utilization Management
Medical Claims & Coding
Escalated Case Resolution
Customer & Provider Relations
Case Documentation
Quality Assurance
Root-Cause Analysis
Process Improvement
Team Coaching & Training
AWARD
New York Life Service Superstar Recipient — 2026
Timeline
Integrated Short-Term Disability Claim Manager
NEW YORK LIFE
04.2024 - CurrentRead More
Short-Term Disability Claim Manager
NEW YORK LIFE
07.2020 - 04.2024Read More
Senior Medicare Complaint & Appeal Analyst
AETNA
03.2019 - 07.2020Read More
Medicare Complaint & Appeal Analyst
AETNA
07.2017 - 03.2019Read More
Medicare Grievance & Appeal Coordinator
AETNA
10.2015 - 07.2017Read More
Clinical Service Representative
UPMC HEALTH PLAN
10.2014 - 10.2015Read More
Engagement Specialist
UPMC HEALTH PLAN
02.2014 - 10.2014Read More
Edinboro University
Bachelor of Arts from Criminal Justice
Read More