JOSSELINE PHILIPPE
ALPHARETTA,GA
Summary
Clinical Appeals Nurse with deep knowledge of federal guidelines for medical review and resolution of member and provider appeals. Ability to handle multiple projects simultaneously with a high degree of accuracy; excellent time management and problem-solving skills. Organized and dependable; successful at managing multiple priorities.
Overview
26
26
years of professional experience
1
1
Certification
Work History
Clinical Appeals Analyst
Healthfirst
07.2021 - 06.2023
- Managed a high volume of cases, prioritizing tasks effectively and meeting strict deadlines for appeals resolutions.
- Navigated regulatory requirements proficiently, adhering to state and federal guidelines throughout the appeals process. Highly knowledgeable in Medicare and Commercial regulatory requirements.
- Utilized guidelines and review tools such as InterQual to conduct extensive research and analyze grievance and appeal issues.
- Streamlined workflows for faster decision-making, evaluating medical records and other documentation to support appeals decisions.
- Collaborated with interdisciplinary teams to ensure accurate claims adjudication, reducing errors and inconsistencies in the review process.
- Communicated complex information clearly to stakeholders, presenting findings and recommendations to guide decision-making processes.
- Maintained detailed records and organized documentation to facilitate smooth appeals processing, ensuring all relevant information was readily available for review.
- Improved the efficiency of the appeals process by reviewing and analyzing claim denials and discrepancies.
- Enhanced customer satisfaction with timely resolution of appeals, addressing concerns thoroughly and professionally.
Clinical Appeals Manager
Kaiser Permanente
04.2009 - 06.2021
- Responsible for all operations for both member and provider appeals requests, ensuring that all appeals are resolved within timely compliance and meeting all federal guidelines for both Medicare and Commercial lines of business.
- Accomplished multiple tasks within established timeframes.
- Evaluated employee performance and conveyed constructive feedback to improve skills.
- Streamlined workflows by identifying bottlenecks in existing systems and proactively addressing these challenges through appropriate solutions implementation.
- Established performance goals for employees and provided feedback on methods for reaching those milestones.
- Assisted in organizing and overseeing assignments to drive operational excellence.
- Ensured compliance with industry regulations and legal requirements by implementing comprehensive policies and training programs for staff members.
- Drove operational efficiency through data-driven decision-making processes, leveraging analytics tools for informed strategy development.
- Defined clear targets and objectives and communicated to other team members.
- Cultivated positive rapport with fellow employees to boost company morale and promote employee retention.
- Managed and motivated employees to be productive and engaged in work.
- Championed diversity and inclusion efforts within the workplace, resulting in an inclusive environment that fostered creativity and innovation among employees from various backgrounds.
- Facilitated successful cross-functional collaborations for the completion of key projects, fostering strong working relationships among team members.
- Onboarded new employees with training and new hire documentation.
- Established team priorities, maintained schedules and monitored performance.
- Organized and detail-oriented with a strong work ethic.
- Self-motivated, with a strong sense of personal responsibility.
Appeals Manager/Business Consultant
Aetna
09.1997 - 12.2008
- Responsible for all member and provider appeals operations leading a successful team of both clinical and non-clinical members.
- Developed detailed plans based on broad guidance and direction.
- Managed and motivated employees to be productive and engaged in work.
- Established performance goals for employees and provided feedback on methods for reaching those milestones.
- Accomplished multiple tasks within established timeframes.
- Established team priorities, maintained schedules and monitored performance.
- Onboarded new employees with training and new hire documentation.
- Developed a strong company culture focused on employee engagement, collaboration, and continuous learning opportunities.
- Exercised leadership capabilities by successfully motivating and inspiring others.
- Completed paperwork, recognizing discrepancies and promptly addressing for resolution.
- Skilled at working independently and collaboratively in a team environment.
- Used critical thinking to break down problems, evaluate solutions and make decisions.
Education
Bachelor of Science - Nursing
Lehman College of The City University of New York
The Bronx, NYSkills
- Medical Records Review using established standards of care guidelines/requirements to ensure correct decision making process
- Benefits review and Insurance policy coverage knowledge to ensure regulatory compliance
- Knowledgeable in Medicare and Commercial regulatory requirements for both member and prover appeals
- Self-Directed and skilled in using all Microsoft office apps
Certification
Registered Professional Nurse-State of Georgia-RN133417
Timeline
Clinical Appeals Analyst
Healthfirst
07.2021 - 06.2023
Clinical Appeals Manager
Kaiser Permanente
04.2009 - 06.2021
Appeals Manager/Business Consultant
Aetna
09.1997 - 12.2008
Bachelor of Science - Nursing
Lehman College of The City University of New York