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Hi, I’m
Gingy Niles
Health Care
Rosedale,NY
Each small task of everyday life is part of the total harmony of the universe.
Saint Thérèse de Lisieux
Summary
My goal is to obtain a position in which I may utilize my extensive experience within the Healthcare industry. I am a detail-oriented team player with strong organizational skills. I have the ability to handle multiple projects simultaneously with a high degree of accuracy. I am seeking a position where there is room for growth and opportunities to learn new policies and procedures. I have exceptional oral and written skills, as well as the ability to build rapport and work cooperatively with others.
Overview
18
years of professional experience
2
years of post-secondary education
Work History
Bright HealthcareMinneapolis, MN
Remote Provider Dispute Analyst
09.2021 - Current
Job overview
- Responsible for coordinating provider disputes from receipt to resolution
- Investigates and responds to provider disputes in accordance with federal and state laws and department policies regarding quality, productivity and timelines.
- Trains new hires on disputes process as well as training employees on systems utilized daily to create and resolve provider disputes.
- Works with Utilization Management department regarding authorization for providers and facilities.
- Resolves complaints and appeals related to claim denials
- Follows up on issues to make sure they are closed in a timely manner.
- Prepares written summaries of each provider dispute.
- Works with claims department to have provider and facility claims reprocessed in a timely manner.
- Researches and analyzes individual parties' positions to understand dispute background.
- Advises parties on dispute resolution processes, policies and procedures, helping disputants make informed choices.
- Assists with day-to-day operations, working efficiently and productively with all team members.
- Drives dispute resolutions using effective problem-solving and by guiding mutual understanding of opposing viewpoints.
- Prepares written opinions or decisions regarding cases.
- Analyzes, researches and resolves payment claims within required timeframes.
Healthfirst InsuranceNew York, NY
Service Agent
11.2020 - 09.2021
Job overview
- Answered incoming member and provider calls in a high volume call center.
- Problem solver of daily issues in regards to member reimbursements and provider payments.
- Assisted members with claims and authorization issues.
- Contacted doctors and facilities regarding billing issues
- Assisted members with benefit related questions, inquiries and issues.
- Updated member demographics.
- Resolved member calls in a timely manner
- Assisted members with claims and authorization issues.
- Assisted members in appealing denied services.
- Contacted doctors and facilities regarding billing issues
- Assisted members with benefit related questions, inquiries and issues
- Assisted members in filing grievances against providers and contracted vendors.
- Responded to questions regarding the Fair Hearing process.
- Utilized EPaces to verify Medicaid eligibility, exclusion and exemption codes.
- Documented all client calls and outcomes.
Health Care PartnersGarden City, NY
Complaints and Grievance Coordinator
10.2016 - 09.2020
Job overview
- Coordinated complaints and grievances submitted by providers from receipt to resolution.
- Investigated and responded to provider complaints, appeals and grievances in accordance with federal and state laws and department policies regarding quality, productivity and timelines.
- Logged, tracked and processed appeals and grievances forwarded to the Complaints and Grievance team.
- Maintained all documentation associated with processing and handling of appeals and grievances to comply with regulatory standards while maintaining an accurate, complete appeals/grievance record in the electronic database
- Conducted research including requesting member/provider records, organizing documentation and preparing written summaries of cases including the resolutions for complaints and grievance files when required.
- Assisted in resolving provider complaints related to service authorization and claims concerns.
- Created certified mail tracking log to track all grievance and appeals issues received via certified mail.
Health Care PartnersGarden City, NY
Delegation Coordinator
10.2015 - 10.2016
Job overview
- Coordinated appeals from receipt to resolution
- Responded to provider appeals requests in accordance with federal and state laws and department policies regarding quality, productivity and timeliness.
- Conducted research including requesting member/provider records, organizes documentation and prepares to submit to Emblem Health.
- Logged, tracked and processed appeals and grievances forwarded to Emblem Health.
- Maintained all documentation associated with processing and handling of appeals to comply with regulatory standards while maintaining an accurate, complete appeals/grievance record in the electronic database.
- Assisted with expediting the processing of claims
- Created monthly tracking report to track all expedited appeal issues received from Emblem
- Created monthly tracking report for Liberty Health Advantage and Emblem denials.
Health Care PartnersGarden City, NY
Team Leader
12.2013 - 10.2015
Job overview
- Assisted in supervising the day-to-day operations of the Quality Improvement Team.
- Logged, tracked and processed appeals and grievances forwarded to the appeals and grievances team.
- Delegated duties to staff.
- Made sure performance levels were maintained.
- Acted as a resource to staff members.
- Maintained all documentation associated with processing and handling of appeals and grievances to comply with regulatory standards while maintaining an accurate, complete appeals/grievance record in the electronic database.
- Conducted research including requesting member/provider records, organizes documentation and prepares written summaries of cases including the resolutions for appeals and grievance files when required.
- Assisted in resolving member and provider complaints related to service authorization and claims concerns.
- Created correspondence letters and emails for resolved member and provider issues.
- Created monthly tracking report to track all grievance and appeals issues received.
Health Care PartnersGarden City, NY
Grievance and Appeals Coordinator
03.2011 - 12.2013
Job overview
- Coordinated appeals and grievances from receipt to resolution
- Investigated and responded to member and provider complaints, appeals and grievances in accordance with federal and state laws and department policies regarding quality, productivity and timeliness.
- Logged, tracked and processed appeals and grievances forwarded to the appeals and grievances team.
- Maintained all documentation associated with processing and handling of appeals and grievances to comply with regulatory standards while maintaining an accurate, complete appeals/grievance record in the electronic database.
- Conducted research including requesting member/provider records, organizes documentation and prepares written summaries of cases including the resolutions for appeals and grievance files when required.
- Assisted in resolving member and provider complaints related to service authorization and claims concerns.
- Created correspondence letters and emails for resolved member and provider issues.
- Created monthly tracking report to track all grievance and appeals issues received.
Health Care PartnersGarden City, NY
House Provider Relations Representative
02.2008 - 03.2011
Job overview
- Served as a liaison between HealthCare Partners, MSO and contracted providers to explain coverage terms, contractual questions and answer inquiries.
- Reviewed and resolved escalated claims issues
- Educated providers in regards to contractual agreements and company policy.
- Answered inquiries from providers and hospital representatives.
- Responded to inquiries in regards to escalated claims, authorization and provider compliance issues.
- Created monthly provider activity reports to assist department in tracking issues.
- Researched and updated provider data.
- Supported field representatives by providing provider roster information, provider profile data and verifying provider agreements.
Health Care PartnersGarden City, NY
Customer Service Representative
10.2005 - 02.2008
Job overview
- Answered incoming member and provider calls in a high volume call center.
- Reviewed and provided information in regards to member claims
- Answered questions regarding claim status, authorization status and member eligibility.
- Accurately documented all live customer interactions and furnished relevant follow-up correspondence.
- Facilitated in the correction of claim issues.
Education
LaGuardia Community College of The City University of New YorkLong Island City, NY
from Liberal Arts And Sciences
09.1996 - 09.1998
Skills
Knowledge of medical claims policies and proceduresundefined
Software
Microsoft Excel
One Drive
Powerpoint
Outlook
Availability
See my work availability
Not Available
Available
monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Timeline
Remote Provider Dispute Analyst
Bright Healthcare
09.2021 - Current
Service Agent
Healthfirst Insurance
11.2020 - 09.2021
Complaints and Grievance Coordinator
Health Care Partners
10.2016 - 09.2020
Delegation Coordinator
Health Care Partners
10.2015 - 10.2016
Team Leader
Health Care Partners
12.2013 - 10.2015
Grievance and Appeals Coordinator
Health Care Partners
03.2011 - 12.2013
House Provider Relations Representative
Health Care Partners
02.2008 - 03.2011
Customer Service Representative
Health Care Partners
10.2005 - 02.2008
LaGuardia Community College of The City University of New York
from Liberal Arts And Sciences
09.1996 - 09.1998
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