Kizzie Wilkins
Elk Grove,CA
Summary
Detail-oriented and experienced Appeals and Grievances Coordinator with a proven track record of managing member complaints and appeals in compliance with healthcare policies and regulatory standards. Skilled in case management, claims processing, and resolution of complex issues to ensure member satisfaction and organizational compliance. Adept at collaborating with cross-functional teams to identify process improvements and enhance operational efficiency.
Overview
10
10
years of professional experience
Work History
Case Manager – Appeals and Grievances
Artech
03.2024 - Current
- Manage appeals and grievances processes while adhering to all regulatory requirements
- Provide case management services to resolve member concerns promptly and effectively
- Collaborate with multidisciplinary teams to address root causes of complaints
Senior Appeals and Grievances Specialist
TotalMed
09.2022 - 02.2024
- Investigated and resolved escalated appeals and grievances within compliance standards
- Streamlined workflows to improve resolution time and efficiency
- Maintained detailed and accurate records for audits and reporting
Appeals and Grievances Specialist
Molina Healthcare
02.2021 - 05.2022
- Handled member grievances and appeals, ensuring timely and satisfactory resolution
- Conducted trend analysis to identify systemic issues and recommended process improvements
- Prepared comprehensive documentation for regulatory compliance
Claims and Appeals Specialist
BroadPath Healthcare Solutions
06.2018 - 01.2021
- Processed claims appeals, ensuring alignment with organizational policies and procedures
- Provided clear communication to members and providers regarding appeal decisions
- Assisted in quality assurance initiatives to enhance claims accuracy
Grievance and Appeals Coordinator
Blue Shield of California
03.2015 - 05.2018
- Facilitated resolution of member grievances and appeals in a timely manner
- Ensured compliance with state and federal healthcare regulations
- Created detailed case summaries and reports for internal and external stakeholders
Education
High School Diploma -
Discovery High School
Sacramento, CA06-2003
Skills
Extensive knowledge of appeals and grievances processes and regulations (CMS, NCQA, HIPAA)
Case management and resolution of escalated member complaints
Claims processing and adjudication expertise
Proficient in creating detailed case documentation and reports
Strong analytical and problem-solving skills
Effective communication and collaboration with internal and external stakeholders
Proficiency in healthcare systems and software (eg, Facets, QNXT, or similar platforms)
Time management and ability to meet strict deadlines
Timeline
Case Manager – Appeals and Grievances
Artech
03.2024 - Current
Senior Appeals and Grievances Specialist
TotalMed
09.2022 - 02.2024
Appeals and Grievances Specialist
Molina Healthcare
02.2021 - 05.2022
Claims and Appeals Specialist
BroadPath Healthcare Solutions
06.2018 - 01.2021
Grievance and Appeals Coordinator
Blue Shield of California
03.2015 - 05.2018
High School Diploma -
Discovery High School