Maureen O'Hara
Quincy,MA
Summary
Dedicated, articulate, motivated and personable professional with exceptional customer service skills, seeks challenging career-continuation where broad experience, past achievements and strong capabilities will be fully utilized to provide exceptional service.
Overview
16
16
years of professional experience
Work History
Appeals and Grievance Analyst
Harvard Pilgrim Healthcare
09.2014 - 03.2021
- In the role of Appeals and Grievances Analyst, my responsibilities included, but were not limited to, the following: Managing assigned member appeals and grievances and all formal complaint cases that were filed through the CEO’s office; this process required investigating and researching the claim starting with the initial submittal and continuing through the resolution of the case
- Acting as member advocate to clearly communicate the appeals and complaints process, both orally and in writing
- Providing and explaining information to members on product and benefit designs
- Working with internal departments and/or external providers to resolve issues and research information submitted to determine final approval/denial status
- Ensuring all adverse determinations have been reviewed for medical necessity prior to final decisions and that they are compliant with state regulatory requirements that are set forth by NCQA, DOI and DOR
- Executing appeals and complaint decisions, including claim payments and authorizations
- Delivering optimal customer service by working cross functionally with internal business units, as well as external stakeholders, such as physicians, attorneys and elected officials.
Senior Member Services Representative
Harvard Pilgrim Healthcare
06.2008 - 09.2014
- In the role of Senior Member Services, my responsibilities included, but were not limited to, the following: Managing calls to resolve customer inquiries, complaints and issues regarding HPHC policies, procedures, benefits, eligibility, enrollment and billing
- Documenting customer feedback and complaints utilizing department policies, procedures and guidelines
- Categorizing and logging customer calls with the appropriate sequence codes
- Utilizing knowledge of web based tools to accurately promote, educate and coach customers in the navigation and use of HPHC’s website
- Assessing the urgency of a situation and interacting effectively with the member
- Considering and proposing creative alternatives to difficult situations/issues.
Senior Member Services
Blue Cross Blue Shield
03.2005 - 08.2007
- In the role of Senior Member Services, my responsibilities included, but were not limited to, the following: Providing high quality and caring customer service in a call center environment
- Researching, investigating and resolving member issues and inquiries
- Advising and educating members on healthcare benefits and policies
- Offering information to potential members on different product types
- Documenting outcome for accurate tracking and analysis.
Education
Liberal Arts Courses -
Quincy College
Hotel Hospitality Management & Tourism Courses - Airline Travel And Tourism
Bay State College
Boston, MASystems & Procedures Training -
Blue Cross Blue Shield
Skills
- Risk Mitigation
- Audit Support
- Workflow Analysis
- Information Gathering
- Effective Communication Methods
- Conflict Resolution
- Emotional Intelligence
- Critical Thinking/Problem Solving
- Interpersonal Skills/Relationships
- Leadership/Ownership
Additional Information
Volunteer Experience :
North Quincy High School Girls Soccer Boosters, Quincy, MA
Volunteer, July 2019-December 2023
North Quincy High School Girls Lacrosse Boosters, Quincy, MA
Volunteer, March 2020-June 2024
Volunteer Community Service
Father Bills MainSpring, Quincy, MA
Serving and Delivering Food to Residents
Volunteer, March 2020-Current Date
Fort Square Presbyterian Church. Quincy, MA
Annual Coat & Blanket Drive
Volunteer, November 2021-Current
Community Cleaner Greener Day (Annual)
Manet Community Health Center/Quincy Public Library
Volunteer Annually
Timeline
Appeals and Grievance Analyst
Harvard Pilgrim Healthcare
09.2014 - 03.2021
Senior Member Services Representative
Harvard Pilgrim Healthcare
06.2008 - 09.2014
Senior Member Services
Blue Cross Blue Shield
03.2005 - 08.2007
Liberal Arts Courses -
Quincy College
Hotel Hospitality Management & Tourism Courses - Airline Travel And Tourism
Bay State College
Systems & Procedures Training -
Blue Cross Blue Shield
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