Kelsey Himes
Pflugerville,TX
Summary
Highly skilled, organized, and detail orientated professional. Committed to providing exceptional service and ensuring customer satisfaction. Strong communication and problem-solving abilities. Seeking to leverage skills and experience to contribute to the success of a reputable organization.
Overview
9
9
years of professional experience
Work History
Grievance & Appeals Representative 3
Humana
03.2022 - Current
- Created, composed and maintained appeal response templates.
- Responded to attorney inquiries in regard to legal documents received pertaining members.
- Coordinated with senior specialist to compose appeal responses.
- Acted as a departmental resource on appeals matters.
- Checked documentation for accuracy and validity on updated systems.
- Verified client information by analyzing existing evidence on file.
- Maintained strong knowledge of basic medical terminology to better understand services and procedures.
Grievance & Appeals Coordinator II
Superior Health Plan Inc
05.2017 - 03.2022
- Reviewed appeals, complaints and claims from providers, determined validity and helped build satisfactory resolutions.
- Managed time efficiently in order to complete all tasks within deadlines.
- Understood requirements for disputes, gathered evidence to support claims and prepared customer cases to handle appeals.
- Conducted full claim and appeal investigations and reported updates and resolutions.
- Responded to inquiries by answering questions, providing information and directing providers to appropriate resources.
- Maintained knowledge of benefits claim processing, claims principles, medical terminology, appeal procedures, and HIPAA regulations.
- Evaluated medical claims for accuracy and completeness and researched missing data.
- Researched and resolved complex medical claims and appeal issues to support timely processing.
Enrollment Processor II
Superior Health Plan Inc
04.2016 - 03.2017
- Maintained detailed and accurate records between multiple databases and programs.
- Checked documentation for accuracy and validity on updated systems.
- Maintained confidentiality of patient eligibility, records, and health statuses.
- Verified client information by analyzing existing evidence on file.
- Maintained and uploaded member eligibility and demographics received from state agencies.
Program Coordinator II (Team Lead)
Superior Health Plan Inc
08.2014 - 03.2016
- Ensure staff competency on current work processes through training and ongoing coaching.
- Responsible for maintaining and reporting monthly errors, implementing corrective actions to improve accuracy.
- Monitor and track the knowledge required to create and modify authorizations, ensuring compliance with regulatory requirements.
- Oversee the agent group report and comparison report, identifying trends and areas for improvement.
- Scheduled and supervised staff meetings to discuss new ideas and update participants on program details and milestones.
- Created and delivered program training and education to keep participants knowledgeable about program and provide necessary skills to participate productively.
Education
No Degree -
Prairie View A & M University
Prairie View, TXHigh School Diploma -
Hendrickson High School
Pflugerville, TX05.2007
Skills
- Strong leadership and team management abilities, with a focus on fostering a positive and collaborative work environment
- Excellent problem-solving and analytical skills, with the ability to identify and address issues proactively
- Effective communication and interpersonal skills, with the ability to build rapport and establish positive relationships with team members and stakeholders
- Exceptional organizational and time management skills, with the ability to prioritize tasks and meet deadlines
Timeline
Grievance & Appeals Representative 3
Humana
03.2022 - Current
Grievance & Appeals Coordinator II
Superior Health Plan Inc
05.2017 - 03.2022
Enrollment Processor II
Superior Health Plan Inc
04.2016 - 03.2017
Program Coordinator II (Team Lead)
Superior Health Plan Inc
08.2014 - 03.2016
No Degree -
Prairie View A & M University
High School Diploma -
Hendrickson High School
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