Luisa Brochero
Haines City
Summary
Detail-oriented individual with exceptional communication and project management skills. Proven ability to handle multiple tasks effectively and efficiently in fast-paced environments. Recognized for taking proactive approach to identifying and addressing issues, with focus on optimizing processes and supporting team objectives. Currently pursuing full-time role that presents professional challenges and leverages interpersonal skills, effective time management, and problem-solving expertise.
Overview
10
10
years of professional experience
Work History
Lead, Grievance & Appeals
Molina Healthcare Inc.
06.2021 - 02.2025
- Experience in claims, utilization review, appeals, and member services
- Coordinate and supervise daily / weekly / monthly activities of a 5 - 12-person team including setting priorities for the team to ensure task completion and performance goals are met
- Analyze and identify trends for all appeals and grievances
- Ensuring professional handling of all member grievances for all lines of business
- Ensure that appeals and grievances meet NCQA, CMS, federal and state-mandated timelines
- Oversaw daily operations of the department, ensuring smooth workflow and timely completion of tasks.
- Collaborated with cross-functional teams to gather necessary documentation and evidence to support the grievance process.
- Managed high-stress situations with professionalism, ensuring that grievances were handled promptly and accurately even under tight deadlines or heavy caseloads.
- Acted as a departmental resource on grievance matters.
- Conducted comprehensive training sessions for new hires on proper procedures for processing grievances and managing caseloads.
- Enhanced overall department efficiency by developing and implementing standardized procedures for handling grievance cases.
- Optimized internal communication channels between departments to ensure seamless coordination on complex grievances cases requiring input from multiple sources.
- Played a key role in multiple successful audit reviews by maintaining meticulous records and upholding strict compliance standards in all grievance-related activities.
- Assisted with development of grievance functions, policies and procedures and documentation.
- Contributed to team growth by actively participating in peer mentoring initiatives designed to improve overall departmental skill sets and knowledge.
- Checked documentation for accuracy and validity on updated systems.
- Maintained strong knowledge of basic medical terminology to better understand services and procedures.
Grievance & Appeals Representative
CarePlus Health Plans
01.2020 - 06.2021
- Managed sensitive client information with confidentiality and discretion, maintaining trust between customers and the company.
- Researched and resolved written complaints submitted by consumers and physicians or providers.
- Obtained additional documentation required for case review.
- Decreased case backlog by effectively prioritizing and managing high-volume caseloads.
- Enhanced the accuracy of appeal decisions through thorough research and fact checking.
- Provided excellent customer service by actively listening to customer concerns and empathetically addressing their needs throughout the appeals process.
- Conducted comprehensive reviews of claim denials, identifying errors or discrepancies that led to successful reversals on appeal.
- Achieved higher success rates on appeal cases by closely analyzing denial reasons and crafting persuasive arguments for reconsideration.
- Examined case to initiate clinical review.
- Completed documentation of final appeals or grievance determination using appropriate templates.
- Collaborated with cross-functional teams to ensure proper handling of complex cases, resulting in more accurate outcomes.
- Rendered decision for non-clinical complaints using sound, fact-based decision making.
- Maintained up-to-date knowledge on industry regulations and guidelines to ensure compliance during the appeals process.
- Submitted verbal and written notification to members and providers.
- Processed and finalized appeals and grievances within agreed-upon turnaround time.
Patient Financial Representative
Baptist Hospital
03.2018 - 05.2019
- Supported hospital's mission to provide quality healthcare by accurately calculating patients'' financial responsibilities using established guidelines.
- Improved patient satisfaction by providing accurate and timely billing information.
- Served as a liaison between patients, providers, and insurance companies, facilitating communication around financial matters.
- Established financial arrangements for self-pay patients.
- Ensured patient privacy by adhering to all HIPAA regulations during daily tasks and interactions.
- Facilitated a smooth registration process for emergency room patients, ensuring accurate data collection and quick access to care.
- Helped customers understand and fill out applicable forms.
- Provided guidance to patients on available payment options, working with them to establish a feasible plan for covering their financial obligations.
- Accurately reviewed and updated patient and financial information.
Senior Appeals Coordinator
UnitedHealthcare
05.2016 - 03.2018
- Conducted appeal and reviews to ensure federal regulations are followed
- Prepared and presented compliance reports to management
- Collaborated with cross-functional teams to address complex cases, ensuring accurate and fair resolutions.
- Conducted proactive audits of closed cases to identify areas of improvement in the appeals process.
- Increased client satisfaction by providing thorough and timely responses to inquiries regarding appeal status and outcomes.
- Managed high caseloads effectively while maintaining strict deadlines for case resolution milestones.
- Provided exceptional customer service by addressing concerns empathetically while remaining focused on achieving positive outcomes for the company.
- Reduced backlog of pending appeals through effective prioritization and time management strategies.
Customer Service Representative
Preferred Care Partners
10.2014 - 05.2016
- Managed high-stress situations effectively, maintaining professionalism under pressure while resolving disputes or conflicts.
- Resolved customer complaints with empathy, resulting in increased loyalty and repeat business.
- Handled escalated calls efficiently, finding satisfactory resolutions for both customers and the company alike.
- Responded to customer requests for products, services, and company information.
- Enhanced customer satisfaction by promptly addressing concerns and providing accurate information.
- Developed strong product knowledge to provide informed recommendations based on individual customer needs.
- Maintained detailed records of customer interactions, ensuring proper follow-up and resolution of issues.
- Assisted customers in navigating company website and placing online orders, improving overall user experience.
- Analyzed customer service metrics to identify trends and develop strategies for improvement.
- Trained new Customer Service Representatives on company policies, procedures, and best practices.
- Participated in training programs to enhance product knowledge and customer service skills.
- Investigated and resolved customer inquiries and complaints quickly.
- Educated customers about billing, payment processing and support policies and procedures.
Education
ASN - RN
Florida National University
Hialeah, FL12-2026
Vocational - Patient Care Technician
Everest University
Miami, Florida04.2014
High School Diploma -
Ronald W. Reagan Doral Senior High
Doral, Florida06.2011
Skills
- Case analysis
- Workflow management
- Grievance and Appeals handling
- Issue identification
- HIPAA compliance
- Effective communication
- Strong analytical skills
- Medical terminology
- Documentation expertise
- Teamwork and collaboration
- Customer service
- Time management
- Attention to detail
- Problem-solving abilities
- Multitasking
- Verbal and written communication, both English and Spanish
- Microsoft office
- Computer proficiency
- Coverage determination
- Skilled in PEGA, FACETS, SalesForce, Member360, QNXT, CVS Caremark, DataHealthcare Exchange and more
- Training and mentoring
- Goal oriented
- Staff management
- Process monitoring and improvement
- Conflict resolution
- Coaching and mentoring
- Audit reporting
Languages
Spanish
Native or Bilingual
Timeline
Lead, Grievance & Appeals
Molina Healthcare Inc.
06.2021 - 02.2025
Grievance & Appeals Representative
CarePlus Health Plans
01.2020 - 06.2021
Patient Financial Representative
Baptist Hospital
03.2018 - 05.2019
Senior Appeals Coordinator
UnitedHealthcare
05.2016 - 03.2018
Customer Service Representative
Preferred Care Partners
10.2014 - 05.2016
ASN - RN
Florida National University
Vocational - Patient Care Technician
Everest University
High School Diploma -
Ronald W. Reagan Doral Senior High
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