Summary
Overview
Work History
Education
Skills
Additional Experience
Timeline
Generic

Lindsey Wilson

Brunswick,GA

Summary

Healthcare Grievance & Appeals Representative with expertise in CMS/HIPAA compliance, claims research, appeals processing, and member advocacy. Skilled in resolving escalated issues, drafting regulatory letters, and leveraging systems such as Salesforce, QNXT, Avaya, and Microsoft Office Suite. Proven ability to handle high-volume caseloads with 95%+ accuracy and strict regulatory deadlines.

Overview

8
8
years of professional experience

Work History

Grievance & Appeals Representative 3

Humana
05.2023 - Current
  • Investigate and resolve appeals across three lines of business: Medicaid, Commercial, and Dual (Medicare/Medicaid) in strict compliance with CMS, HIPAA, and state/federal regulations.
  • Review and analyze complex medical and pharmacy claims (up to $250K) to confirm benefit eligibility and coverage accuracy.
  • Draft and issue regulatory-compliant resolution letters and case summaries for members, providers, and state agencies. • Manage 35–40 cases weekly, consistently achieving 100% compliance with mandated deadlines.
  • Conduct root-cause investigations of escalated cases, ensuring fair resolution and alignment with company and regulatory policies.
  • Collaborate with medical directors, claims processors, and provider networks to resolve multi-layered appeal issues.
  • Utilize systems including Salesforce, Avaya, SharePoint, Microsoft Office Suite (Word, Excel, Outlook, Teams), ServiceNow, and Citrix to process, track, and document appeals with 98%+ accuracy.
  • Recognized for maintaining 95%+ quality scores while balancing a high-volume caseload across three distinct insurance lines.
  • Obtained additional documentation required for case review.
  • Researched and resolved written complaints submitted by consumers and physicians or providers.
  • Examined case to initiate clinical review.
  • Remained knowledgeable regarding company policies and procedures and current developments within operational departments.
  • Processed and finalized appeals and grievances within agreed-upon turnaround time.
  • Submitted verbal and written notification to members and providers.
  • Provided outreach for additional information for appeals and grievances.

Customer Service Representative

Humana
03.2021 - 05.2023
  • Supported Medicare, Medicaid, and Commercial members via Go365 inbound calls.
  • Troubleshot app, portal, and device issues, achieving a 92% first-call resolution rate.
  • Audited 200+ submissions monthly to ensure compliance and accuracy.
  • Contributed to the Impact Planning Team, reducing repeat inquiries by 15%.

Debt Collection Specialist

RGL Associates
08.2017 - 03.2021
  • Managed 200+ delinquent accounts monthly, negotiated settlements, and exceeded recovery goals.
  • Used skip tracing software to increase recovery rates by 20%.

Education

Associate's Degree - General Education

Troy University
Troy, Alabama
06.2021

High School Diploma -

Brunswick High School
Brunswick, GA
05.2002

Skills

  • Grievances & Appeals Claims Resolution CMS/HIPAA Compliance
  • Medicare, Medicaid, Commercial Insurance Member Advocacy
  • Salesforce QNXT Avaya Microsoft Office
  • Case Documentation Resolution Letters Call Center Operations
  • Negotiation Collections Customer Experience

Additional Experience

  • Cuevas Jones Financial Services – Debt Collection (2016–2017)
  • Hospitality Roles (Clarion Inn, Quality Inn, St. James Suites, 2007–2016) – Leadership & customer service foundation.

Timeline

Grievance & Appeals Representative 3

Humana
05.2023 - Current

Customer Service Representative

Humana
03.2021 - 05.2023

Debt Collection Specialist

RGL Associates
08.2017 - 03.2021

Associate's Degree - General Education

Troy University

High School Diploma -

Brunswick High School

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