Shaniqua Cobb

Resolved enrollee grievances and complaints, ensuring compliance with Medicare and organizational guidelines

Investigated grievance cases by analyzing claim history, provider documentation, and member concerns to ensure accurate resolutions

• Conducted investigations to resolve discrepancies and uphold claim integrity across all cases
• Ensure all case decisions meet regulatory and quality standards while maintaining strict deadlines
• Managed caseload of 75 cases, emails, and faxes daily from providers.
• Reviewed case files to ensure thorough investigation of complaints and appeals.
• Analyze complex medical documentation to support evidence-based decisions
• Make outbound calls to members or providers to request documentation, clarify case details or address outstanding issues.
• Conduct analytic reviews of clinical documentation to determine case validity, including investigative work to find the denial.

• Processed high-volume medical claims while ensuring accuracy and compliance with insurance guidelines
• Investigated and resolved billing and coding issues for providers and enrollees, resulting in faster claim resolution times
• Communicated claim determinations clearly, leading to fewer confusion and repeat inquiries
• Monitored claim status and proactively updated clients, contributing to higher customer satisfaction
• Developed educational content to guide users in correcting rejected or denied claims
• Handled 70 incoming calls daily from providers, addressing inquiries and issues.

• Guided members in selecting and enrolling in Medicare and Medicaid plans, addressing coverage questions to enhance understanding
• Informed enrollees about benefits, deductibles, and payment responsibilities to clarify financial obligations
• Resolved member concerns efficiently, preventing escalations and improving customer experience
• Evaluated customer needs to recommend suitable healthcare plans and services, ensuring alignment with individual requirements

Coordinated with medical staff to confirm and optimize appointment availability.

• Scheduled patient appointments using electronic health record system.
• Managed incoming calls for appointment inquiries and effectively rescheduled appointments.
• Organized and maintained appointment calendars for multiple physicians to enhance scheduling efficiency.
• Ensured accurate patient information entry into scheduling software.
• Assisted in scheduling, rescheduling, and canceling appointments for patients.
• Maintained accurate records of patient appointments in computer system.