Jesannie Ortiz
Lauderhill,FL
Summary
Dedicated and results-driven professional with over 7 years of experience in managing appeals and grievances within healthcare and operational/customer service environments. Experienced and skilled in investigating, resolving complex cases, and ensuring compliance with regulatory standards. Seeking to leverage strong problem-solving, communication, and conflict resolution abilities in a challenging role to enhance customer satisfaction and streamline processes. Complaint management, investigative skills, policy compliance, conflict resolution, data analysis, excellent communication, reporting and documentation NCQA, CMS, URAQ, state, and other regulatory guidelines and process of grievances and appeals procedures.
Overview
8
8
years of professional experience
Work History
Grievance Coordinator
Cigna Healthcare
11.2024 - 01.2025
- Served as the primary contact for members and healthcare providers to submit grievances regarding claim denials, billing errors, or service issues, ensuring that all complaints were logged accurately within regulatory timeframes
- Investigated grievances by reviewing claim files, medical records, and policy details, coordinating with external and internal departments/point of contacts, and healthcare professionals, if needed, to gather relevant information
- Analyzed claims processes and recommended corrective actions to resolve systemic issues to ensure that company practices align with plan’s regulations and standards
- Facilitated a resolution for all disputes based on research and findings that were assisted by claims, customer service, legal and external parties, such as providers and regulatory agencies information for a conclusive resolution
- Managed and tracked grievance cases from initiation to closure to ensure compliance with state and federal plan regulations, and documenting all actions taken for audit purposes
- Educated members about their rights and the grievance process, providing clear communication and updates on the status of their cases
- Confirmed strict confidentiality of sensitive members’ information and adhere to privacy regulations such as HIPAA throughout the grievance process
- Assisted fellow grievance coordinators on grievance procedures and the proper handling of members’ complaints
Appeals Specialist
Sarasota Shared Services
06.2024 - 09.2024
- Managed workflow for Humana PPI audits, RAC audits or outpatient appeals and communicates daily with Sr
- Director and/ or manager on trends identified
- Responded to queries within 72 hrs., appropriately documents in Cerner/ClaimIQ/Artiva and tracks all activity in the appeal tracker
- Managed PDFU to assure timely follow up of accounts to effectively move through the revenue cycle
- Completed claim appeals and assisted with other projects as needed
- Submitted requests for medical records, UB’s and itemized bills as needed
- Responsible for being aware of the current department policies and procedures
- Meet or exceed quality and quantity benchmark targets as established by management (productivity, AR days, cash collections, bad debt, past due follow ups)
- Ability to perform all other duties as assigned or requested
Grievances & Appeals Analyst
NationsBenefits
Plantation, FL
10.2022 - 04.2024
- Identified and analyzed the scope of the grievances and/or appeals intake to determine the true type of request for accurate investigational findings
- Ensured the ability and functionality to effectively collect data and established analytical investigational research to provide resolutions based on the findings internal and external resources needed based on the request (grievance/appeals)
- Ensured that the completion of grievances and/or appeals processes were abided by their contractual timeframe based on NCQA, CMS, Medicare and state guidelines
- Provided written and verbal communication of resolutions to grievances and appeals based on the required compliant timeframe of the contractual agreement per plan/ state guidelines
- Completion of impromptu group projects and/or individual assigned duties within urgent timeframes/deadlines as a team and/or independently player
- Implemented and provided an oversight into the grievances and appeals process and procedures for a flowable standard of procedure (SOP)
- Assisted with training and auditing new grievances and appeals analyst to perform functionality of duties confident and companies’ policies and processes
Grievance & Appeals Administrator
MCNA Dental
Fort Lauderdale, FL
03.2017 - 10.2022
- Ensured State and Federal compliance regulations were followed based on plans and state guidelines
- Ensured Medicaid and Medicare requirements followed by URAQ and NCQA credentials per plans’ state guidelines
- Reviewed RFA/RFP contracts with the understanding of the states’ guidelines and regulations per plans
- Provided support of informational scope and required documentation for preparation of state plans’ audit reviews/ state fair hearings and/or independent review organization (IRO) request
- Ensured appeals were issued and conducted by appropriate licensed clinical reviewers including the specialty required for proper completion of review and final determination
- Ensured proficiency in providing adverse/grievance resolution based on final findings from internal/external resources required for full completion
- Provide managerial support for departmental audit reviews amongst other administrators within the team due to seniority and expertise of different state plans and regulations
Front Office Executive
Silver Lakes Dental
Pembroke Pines, FL
09.2013 - 03.2017
- Scheduled appointments for patients needing to continue treatment
- Confirmed and input data of insured and/or non-inured patient’s demographic information and registration in office informational system
- Provided administrative/ secretarial support of the office’s daily operations including but not limited to all telephonic communications and contact to patients, internal/external correspondences, maintaining office files/records and bookkeeping up to date
- Informed patients on general questions that pertain to their treatment, payments, or questions regarding insurance
- Communicated and enforced billing and payment policies of office’s administration and polices
- Performed office managerial skills and settings for office support
Education
Healthcare Administration -
Ashworth College
Norcross, GAHigh School Diploma -
McArthur High
Hollywood, FLSkills
- Cross-Department Collaboration
- Conflict Resolution
- Intercultural Communication Expertise
- Training Delivery Skills
- Cultural Contextual Understanding
References
Upon Request
References
References available upon request.
Timeline
Grievance Coordinator
Cigna Healthcare
11.2024 - 01.2025
Appeals Specialist
Sarasota Shared Services
06.2024 - 09.2024
Grievances & Appeals Analyst
NationsBenefits
10.2022 - 04.2024
Grievance & Appeals Administrator
MCNA Dental
03.2017 - 10.2022
Front Office Executive
Silver Lakes Dental
09.2013 - 03.2017
Healthcare Administration -
Ashworth College
High School Diploma -
McArthur High
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