Fernadine Elor
Lauderhill,FL
Summary
Dynamic Grievance Appeals Specialist with a proven track record at Clear Spring Health, adept at resolving complex disputes and ensuring HIPAA compliance. Skilled in workflow management and effective communication, I excel in analyzing trends and preparing comprehensive documentation, consistently enhancing member satisfaction and operational efficiency.
Overview
7
7
years of professional experience
Work History
Grievance Appeals Specialist
Clear Spring Health
Miramar, FL
03.2022 - Current
- Responsible for thoroughly researching and resolving appeals, disputes, grievances, and complaints from Clear Spring Health members, providers, or external agencies, ensuring compliance with both internal procedures and regulatory deadlines.
- Responsible for thoroughly researching and resolving appeals, disputes, grievances, and complaints from Clear Spring Health members, providers, or external agencies. Ensures all cases are addressed within internal and regulatory timelines. Communicates with members and providers through both written and verbal correspondence to gather information and provide resolution updates.
- Responsible for preparing appeal summaries, drafting correspondence, and documenting findings. May also include analyzing and reporting on trends when requested.
- Resolves and prepares written responses to incoming provider reconsideration requests related to claim payments, claim adjustments, and inquiries from external agencies. Utilizes support systems to research appeals and grievances, determine outcomes, document findings, and analyze trends when needed.
- Researches claims appeals and grievances using internal support systems to determine outcomes. Prepares summaries, drafts correspondence, and documents findings. Provides trend analysis when requested.
Customer Service Representative
Take2telecom
Fort Lauderdale
08.2018 - 05.2020
- Resolved customer inquiries efficiently, ensuring satisfaction and timely support.
- Utilized CRM systems to document interactions and track service issues accurately.
- Collaborated with cross-functional teams to improve service delivery processes.
Education
Plantation High School
Plantation, FL06.2018
Skills
- Workflow management
- Grievance handling
- Issue identification
- HIPAA compliance
- Effective communication
- Documentation expertise
- Time management
- Claims investigation
- New hire training
Timeline
Grievance Appeals Specialist
Clear Spring Health
03.2022 - Current
Customer Service Representative
Take2telecom
08.2018 - 05.2020
Plantation High School