Dalia Bernal

· Manages a team of Grievance Coordinators with responsibility for goal and productivity management, coaching and providing feedback.

· Delivers training to employees as needed and ensures new hires have proper work tools and are trained accordingly.

· Ensures Grievance Coordinators expedite timely request for information and that cases meet compliance.

· Make critical decisions in support of the business as needed.

· Manages all duties within CMS regulatory timeframes and interprets CMS regulations and policies as needed.

· Responsible for ensuring that the team meets/exceeds production and quality goals.

• Achieved results by working with staff to meet established targets.
• Conducted performance evaluations for staff members, identifying areas of improvement.
• Established performance metrics for the team, consistently tracking progress towards goals .
• Generated reports detailing findings and recommendations.
• Manage time and leave for team members.

• Maintained accurate records of all grievance cases, facilitating easier reporting and analysis of trends.
• Improved interdepartmental communication, ensuring timely updates on case progress and resolutions.
• Conducted regular audits of resolved cases to identify potential improvements or errors within the system.
• Cultivated a collaborative work environment with team members, fostering efficiency in addressing grievances.
• Enhanced grievance resolution rates by implementing efficient tracking and monitoring systems.
• Reduced case backlog by prioritizing urgent grievances and effectively delegating tasks to team members.
• Coached team members in techniques necessary to complete job tasks.
• Monitored team performance and provided constructive feedback to increase productivity and maintain quality standards.

• Logs, tracks and process grievances within the required CMS timeframes
• Independently reviews all grievances assigned and applies various regulations to appropriately classify the grievance
• Contact customer to gather information and communicate disposition of case
• Conducts pertinent research in order to evaluate, respond to, and close grievances in accordance with all established regulatory guidelines
• Conducts investigation based on benefit information, claim status, medical authorizations, health plan documents, appeals process, and/or product information
• Prepares written responses to members that appropriately address the grievance
• Build trusting relationships with customers by listening to understand their needs and responding with empathy
• Interaction and collaboration with internal contacts such as but not limited to Customer Service, Provider Operations, Pharmacy Operations, Vision and Dental Administrators, Medical Management and other resources to identify factors necessary for the optimal resolution of complaints
• Assigned as a resource to mentor and assist internal Grievance Administration Division (GAD) Team members with questions on how to investigate and resolve simple and complex grievances
• Assisted with training new staff
• Other duties as assigned by management.

• Managed large amounts of incoming calls from customers regarding questions about their plan
• Discussed customer needs and assisted with the best solution for their individual situations
• Created customer solutions with compassion by listening and selecting the best and fastest solution to customer inquiries
• Provided accurate, valid and complete information by using available resources
• Met personal/customer service team call handling quotas
• Completed application for transfer of plans and submitted electronically to enrollment department for processing
• Maintained up-to-date knowledge of CMS regulations and policies as they apply to healthcare programs by completing all assigned training
• Kept records in system of customer interactions, processed customer accounts and document files
• Followed communication procedures, guidelines and policies.

• Supervised and evaluated the work of Food Stamp and Medicaid eligibility workers and clerical staff who engaged in determining initial and continuing eligibility of clients for public assistance
• Interviewed job applicants and participated in selection of staff, provided training and staff development, ensured that staff maintained an appropriate work flow to meet department standards
• Developed and implemented unit work goals and monitored progress toward goals
• Completed performance assessments
• Conducted group and individual employee conferences to discuss or interpret departmental rules; regulations, policies procedures and performance problems
• Identified and resolved operational problems; received and resolved employee complaints and made recommendations to superiors on difficult and complex personnel matters
• Participated in Quality Control; reviewed case documentation for completeness and accuracy; determined and took necessary action to correct errors
• Conducted monthly staff meetings
• Prepared and presented required reports, including the preparation of appeal summaries
• Identified errors and or potential fraud, taking appropriate action and making appropriate referrals
• Ensured clients received the maximum available benefits in a timely manner.
• Ensured compliance with regulations and standards through regular audits, staff education, and policy updates.
• Resolved conflicts among team members quickly to maintain a positive working environment conducive for continued excellence in patient care.