Overview
Work History
Summary
Education
Skills
Work Availability
Timeline
Generic

Guirlaine Gordon

Grievance & Appeal Representative 3
FT WHITE,FL

Overview

17
17
years of professional experience
6
6
years of post-secondary education

Work History

Grievance & Appeal Representative 3

HUMANA
05.2023 - Current
  • Responsible for reviewing, processing, and resolving complaints and disputes related to medical, insurance, or other claims
  • Also responsible for logging, tracking, and documenting the information and outcomes of each case
  • Comprehensively review and evaluate appeal and grievance requests to identify and classify member and provider appeals
  • Determine eligibility, benefits, and prior activity related to the claims, payment or service in question
  • Provide written acknowledgment of member and provider correspondence
  • Responsible for making verbal contact with the member or authorized representative during the research process to further clarify, as needed, the member's complaint or appeal
  • Research appeal files for completeness and accuracy and investigate deficiencies
  • Consult with internal areas as required (such as the Legal Department) to clarify legal ramifications around complex appeals
  • Follow-up with responsible departments and delegated entities to ensure compliance
  • Accurately and completely prepare cases for medical and administrative review detailing the findings of their investigation for consideration in the plan's determination
  • Monitor daily and weekly pending reports and personal worklists, ensuring internal & regulatory timeframes are met
  • Responsible for monitoring the effectuation of all resolution/outcomes resulting from internal appeals as well as all appeals reviewed through the IRE
  • Prepare written responses to all member and provider correspondence that appropriately address each complainant's issues and are structurally accurate
  • Ensure documentation requirements are met: create and document service requests to track and resolve issues; document final resolutions along with all required data to facilitate accurate reporting, tracking and trending
  • Assessment, analyze, and process policies associated with claim events to establish the company's liability and entitlement
  • Attend as a liaison between grievances & appeals and /or medical management, legal, and/or service operations and other internal departments
  • Carefully document clear case notes
  • Work ODPD and Code Edit Cases.

Consumer Service Operations Representative 2

HUMANA
12.2019 - 05.2023
  • Perform Installation, Implementation, Client Support, Client Services, & Call Center Operations, Msp, Lis
  • Focus on interpretation of area/department policy and methods for completing assignments
  • Demonstrate positive working relationships with peers and effectively manage conflict and attend meetings and training sessions as scheduled
  • Pre-screen and initiating expedited referrals in the application for Federal and State assistance programs
  • Investigates & Settles Claims
  • DSNP
  • Follow Up.

Customer Care Specialist

PRESTIGE HEALTH CARE
10.2014 - 06.2018
  • Receive, Document, & Resolve Customer Inquiries
  • Educate Providers & Employers about Products & Services
  • Grievance & Appeals, Enrollment, Billing, & Claims Research.

Customer Care Specialist

MEDICAID
10.2013 - 10.2014
  • Confer with customers by telephone or in person to provide information about products or services, take or enter orders, cancel accounts, or obtain details of complaints
  • Patient Advocacy, Document, & Update.

Account executive

COMCAST
12.2007 - 05.2013
  • Communicate Various Marketing Packages to Customers
  • Educate & Inform customers utilizing knowledge of products & services
  • Demonstrates consultative sales techniques by using probing questions, clarifying needs, overcoming objections and providing solutions that fits the needs of the customer
  • Offers assistance to customers for non-sales-related calls to the best of ability and seeks to transition it to a sale
  • Educates customers on the Company products, services and experience leveraging job aids and support materials as needed
  • Establishes rapport and promotes relationships by providing a unique positive experience for each customer through personalizing sales interaction.

Summary

Demonstrates strong analytical, communication, and teamwork skills, with proven ability to quickly adapt to new environments. Eager to contribute to team success and further develop professional skills. Brings positive attitude and commitment to continuous learning and growth. Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.

Education

Associate of Science - Nursing

Techni-Pro Institute
Boca Raton, FL
2015 - 2017

Associate of Arts - ARTS

Broward College
Fort Lauderdale, FL
2010 - 2015

Skills

  • Technical Troubleshooting
  • Telephone reception
  • Records Management
  • Customer Support
  • Needs analysis
  • Sales Reporting
  • Client Services
  • Account Servicing
  • Retention Strategies
  • Customer Relations
  • Data entry proficiency
  • Cross-Functional Team Development

Work Availability

monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Timeline

Grievance & Appeal Representative 3

HUMANA
05.2023 - Current

Consumer Service Operations Representative 2

HUMANA
12.2019 - 05.2023

Associate of Science - Nursing

Techni-Pro Institute
2015 - 2017

Customer Care Specialist

PRESTIGE HEALTH CARE
10.2014 - 06.2018

Customer Care Specialist

MEDICAID
10.2013 - 10.2014

Associate of Arts - ARTS

Broward College
2010 - 2015

Account executive

COMCAST
12.2007 - 05.2013

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Guirlaine GordonGrievance & Appeal Representative 3