Leslie Jackson
Moreno Valley,CA
Summary
Customer Service Specialist experienced in resolving customer issues and escalated requests with prompt and knowledgeable support. Achieved operational efficiency and increased customer satisfaction through effective communication and coordination of complex appeals and grievance cases. Focused on establishing communication channels among healthcare providers, patients, and insurance companies to ensure timely issue resolution.
Overview
21
21
years of professional experience
Work History
WFH Appeals and Grievances Coordinator
United Healthcare
09.2021 - 10.2026
- Strategically answer inbound calls from members with both Medicare and Medicaid auth reps, agents, providers and other third parties in reference to plan navigation for government and community and state programs. Daily activities included but were not limited to claims status, billing inquiries, eligibility authorization status, pre/post services, grievances and appeals, also assisted with enrollment for Kaiser North/South plans , assisted with u card cases and investigations coverage determinations, rx overrides, rx rejections, cob updates, website navigation to name a few.
- Delivered concierge and white-glove level service, alleviating burdens and ensuring end-to-end resolution for customers. Serve as a single point of contact for the customer and form a strong relationship to support them and their families Own problem through to resolution on behalf of the member in real time or through comprehensive and timely follow-up with the member Research complex issues across multiple databases and work with support resources to own the resolution of all customer issues and anticipate their future healthcare needs or potential opportunities to improve the experience. Respond to and own consumer inquiries and issues Conduct proactive research on assigned member accounts to identify service issues. Identify Gaps in processes or in coverage and work closely with other departments for process improvement. Rewards, coordinate transportation, eligibility ,and enrollment. Cross-trained as team lead and assisted with new hire training classes, quality assurance call coaching, and compliance training. Provided Education and status on previously submitted pre-authorizations or pre-determination requests health information, medical records, release of information Meet the performance goals established for the position in the areas of: efficiency, call quality, customer satisfaction, first call resolution and attendance.
- Coordinated UnitedHealthcare member care plans with providers and community resources, ensuring access to transportation, housing, utility assistance, and legal support.
- Resolved claims appeals, grievances via email, and chat and phone issues for members by addressing mail order rejections, facilitating timely fills and auto shipments, and serving as liaison with pharmacy Optum Rx.
- Responded to HR-related inquiries regarding leave of absence, disability, and benefits, providing clear and accurate information to assist employee, payroll, life and supplemental policies. Education on enrollment appeals, dependent verifications, Financial account opening and education on Hsa/Fsa and other benefit administration duties as needed .
Provider Services Representative Wfh
Cigna
09.2018 - 09.2020
- Professionally answer inbound calls from, providers, regarding benefits and eligibility, cob updates.
Claims status, on Medicare Supplement/Medicare Advantage plans, life policies and health policies
Reprocessing of claims, policy changes, website navigation, Appeals, 2nd level appeals medical records, as well - Handled provider enrollment, data management, and contracting issues.
- Answered provider calls for Cigna eligibility, benefits, and claim questions.
- Resolved provider inquiries using Cigna systems and service guidelines.
- Explained authorization requirements and network rules to healthcare offices.
Member Services Rep
Hcs Healthcare Scouts
02.2018 - 05.2018
- Answered inbound calls on Pharmacy help desk from members and providers regarding benefits, eligibility, claims status, refills, and prior authorizations for medications. Handled inquiries related to state medicaid programs and other pbm, pdp plans. Also assisted with drug recalls, drug interactions, setting up peer to peer along with assisting local retail pharmacies on processing prescriptions through thoroughly to ensure payment.
Member Service Representative
US Tech Solutions Inc
07.2016 - 02.2017
- Answered inbound calls from members, providers, brokers, beneficiaries, and funeral homes regarding life policies and Medicare Supplement plans, ensuring accurate information delivery
- Managed claims status, benefits eligibility, prior authorizations, and coordination of benefits to support member inquiries
- Supported brokers and agents with resolving rejected applications and final expense claims on life policies, which enhanced processing efficiency.
Hedis Project Assistant
Robert Half / Office Team United Health Care
01.2016 - 05.2016
- Handled inbound calls on provider hotline regarding Hedis Project for Par and non-Par providers for United Health Care, ensuring accurate information dissemination
- Provided general administrative and clerical duties in collection of medical records from hospitals and labs, and doctor's offices from our vendors Altegra, Healthport, and Chartpro
- Sorted and distributed incoming mail to appropriate departments, performed data entry and scanned all documents for hard copy filing system Ehr.
Member Service Representative
Prime Therapeutics LLC
10.2011 - 02.2012
- Handled inbound calls from members and providers regarding blue plans pharmacy benefits, ensuring accurate information delivery.
- Processed mail order payments and managed drug interactions, recalls, prior authorizations, and pharmacy claims in support of members' needs.
- Also assisted local retail pharmacy with processing prescriptions as well.
Customer Service Representative III
Beechstreet A Viant Network/Multiplan
09.2008 - 09.2009
- Handled inbound calls from providers to address claim status, claims appeals, reprocessing, and claim payments within the ppo network.
- Other duties were fee schedules, contracting issues, fee negotiations, provider enrollment, and credentialing providers
- Entered provider data into system to ensure accurate records. , Processed claim appeals to resolve disputes and ensure accurate payments., Handled second-level appeals to facilitate resolution of complex claims..
Provider Service Representative
United HealthCare Services Inc
09.2005 - 02.2008
- Primary responsibilities were to take inbound calls from providers relative to network issues, contracting issues, fee schedules, provider enrollment, and provider data management
- Other duties involved processing 2nd level appeals, for Commercial and Medicare plans.
- Supported provider inquiries for UnitedHealthcare plans and benefit coverage details.
Education
High School Diploma -
Dominguez High School
Compton, CACertification - Medical Billing/Coding
American Career College;
Los Angeles, CASkills
- Health Information Technology
- Epic EMR System
- Appeals/ Grievances
- Compliance Champion
- Specializing in Commercial/ State Government and Private Insurance
- Provider Enrollment
- Credentialing
- Hedis
- Medical billing/Coding
- Medical records
Timeline
WFH Appeals and Grievances Coordinator
United Healthcare
09.2021 - 10.2026
Provider Services Representative Wfh
Cigna
09.2018 - 09.2020
Member Services Rep
Hcs Healthcare Scouts
02.2018 - 05.2018
Member Service Representative
US Tech Solutions Inc
07.2016 - 02.2017
Hedis Project Assistant
Robert Half / Office Team United Health Care
01.2016 - 05.2016
Member Service Representative
Prime Therapeutics LLC
10.2011 - 02.2012
Customer Service Representative III
Beechstreet A Viant Network/Multiplan
09.2008 - 09.2009
Provider Service Representative
United HealthCare Services Inc
09.2005 - 02.2008
High School Diploma -
Dominguez High School
Certification - Medical Billing/Coding
American Career College;